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�_ MINNESOTA UN/QUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name __ _. WELL AND BORING RECORD � � 6 g J � Minnesota Statutes,Chapter 103/ € t nenr�ep�n Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Ot�o 117 23 04 N�� ?� SE�� I6� " '�-I-10 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds . __ Longitude degrees minutes seconds . �'Cable Tool ❑Driven Dug Auger ,�'Rotary ❑Jetted House Number,Street Name,City,and Zip Code ot Well Location or Fire Number � � G'ilJlJ FOX SL� blCOT�I 55391 DRILLING FLUID WELL HYDROFRACTURED? �]Yes ;�No Show exact location of well/boring in section grid with"X" Sketch.�nap of well/boring location. �� From ft.To ft. i /'y� Showing property lines, N f 'roads,buildings,and direction. USE �Domestic . �.Monitoring '_.]Heating/Cooling __;___ __y__ ___�__ ___;_ ` �� `,_,�Noncommunity PWS � i Environ.Bore Hole ��J Industry/Commercial � ` � �,]Community PWS ! �Irrigation j]Remedial __�_____;___ ___:__ __.__ t a -- �,Elevator ';Dewatering ❑ w ; ; ; ; E '—: "—`, CASING MATERIAL Drive Shoe? (�Yes �No HOLE DIAM. —�-----�-----�-----'— T� �'._:. :. >. ; ..`. .--Steel � .l Threaded ❑Welded , , , , 'h Mile j � � , , , , � ; I�`Plastic . --�--- --�-- ---%-- --�- �` + CASING ' ' S ' 1 t +- � Diameter Weight Specifications F---1 Mile--� �_in.to_�,.fj�ft. �_Q Ibs./ft. �� _�_in.to_ �t. PROPERTY OWNER'S NAME/COMPANY NAME in.to _ft. Ibs./ft. �in.to�.�[. �r�� in.to ft. Ibs./fl. in.to ft. OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN 1�0� ^�� `� w Make s n �$� a From ft To ft. PiV�t�th i�tN 55b�49 Type i+iil_ L�ength 4' + 4' J=�•+ : SIoUGauze_ __ •- Set between_.�j$__ft.and�� ft. FITTINGS�„ ~ RECEIVEp STATIC WATER LEVEL Measured from_. __�� ft.,��Below � J Above land surface Date measured � WELL OWNER'S NAME/COMPANY NAME �O}O PUMPING LEVEL(below land surface) / �,�j� ft.after �S hrs.pumping g.p.m. Well!boring owner's mailing address if different than property g61p$i�,3 d above. WELLHEAD COMPLETION . vlT��Q �C Pitless/adapter manufacturer_ .� � '� �- '��>� - � �� "'�R+bdel �Casing Protection �12 in.above grade I� '�At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION /� / Well�iE�� .----NO �l. �� — `! � Grout a i l eat ceme �Bentoni oncrete �� ',Other ��ri;�� `�'� `�� - From _To ft. �=i Yds. ��.Bags HARDNESS OF From To ft �;Yds [�Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO From To R ❑Yds. �Bags _ NEAREST KNOWN SOURCE OF CONTAMINATION CZS Q11Q� .�1 � __ ' i' { � _feet ' � direction - r . type " Well disinfected upon completion? �;'�Yes � �No CI8 .:�� "� PUMP []Not installed Date installed_ ' '-� � � � �� r�� Manufacturer's name Model Number ✓ HP�Volts .�'—�'..) ,�r��/��a ��. ��t Length of drop pipe � f ft. Capacity g.p.m. � �� r � Type: ' ubmersible �, f LS.Turbine �� '.Reciprocating ❑Jet j] Z ABANDONED WELLS Does property have any not in use and not sealed well(s)? [�Yes .�No VARIANCE Was a variance granted from the MDH for this well? �_.J Yes No TNk WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. 7he information contained in this report is irue to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. �Q[i ,�j��Qla �ell Driiling Co�� 1�• Licensee Business Name Lic.or Reg.No. /� r J' �� ; � "� Certified Representative Sigttature CertiTied Rep.No. Date Vi{115:� 1�;,7V� LOCALCUPY 7 7 6 8 5 4 Name of Driller IC 140-0020 HE-01205-12(Rev.12/08)