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� MINNESOTA UN/QUE WELL WELL OP,BORING LOCATION . MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING RECORD � � O G� � Minnesota Statutes,Chapter 1037 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED S�E NE��SW �� 124 " 2-22-49 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ Longitude degrees __ minutes seconds �_�Cable Tool Driven �, i Dug i Auger 17�Rotary _-��,Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �1 � . DRILLING FLUID WELL HYDROFRACTURED? ❑Yes i�Fla Show exact location of well/boring in section grid with"X" Sketch map of well/borin lo�6n. �C� From fL To � ft. ' �' Showing prop r es, � �-"' ` ' � u ion. USE N , ,,,, Domestic �Monitoring ��Heating/Cooling __1_____J___ ___L_. ___L_ J � ��,�� `` oncommunity PWS �]Environ. ore Hole [j Industry/Commercial ' 1 ' ; ""� ��"^� } f� ` �-�,Eevatorniry PWS r]DewaterBg �Remedial . --'-----,------`-----`- � Lj � �� ,,. w ; , i ; E� 1�„^.� �'� ASIN Drive Shoe. L�Yes - No OLE DIAM. ' MATERIAL H C G --�-----�------�-----:-- I]Steel �:�_,,Threaded [j Welded , � � , 'f_Mlle � StiC ' _ la r --,-----.-----�-----:- 1 - 1 ; ' ' � CASING g �� Diameter Wei ht Specifications �` 4 116 �.9 �st�r S 54 F-i M�ie� -.� in.to___ ft. _Ibs./ft. in.to7��ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. _ �in.to ft. �3,��J� �Z�j�h in.to ft. Ibs./ft. in.to ft. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. - � � 8� Make � From ft. To ft. TyPe S�B�e�� Diam._ SIoUGauze •�1�) Length � 'f" � Set between_�"L�ft.and__��ft. FITfIN � � S�fATIC WATER LEVEL Measured(rom tt. � elow �r 1 Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ft.after hrs.pumping g.p.m. Well/boring owner's mailing address if different than properry owner's address indicated above. WELLHEAD COMPLETION ;� q.. �Pitless/adapter manufacturer - 3�'� , . �• ��+�-��-,lModel �Casing Protection _ h.f12 in.above grade �l At-grade(Environmental Well and Boring ONLY) 7^ GROUTING INFORMATION Well grouted �;Yes (.]No Grout materials [�Neat cement �Bentonite []Concrete ❑Other Fom__�To__�.ft. �_ _ �_��,Yds. '�Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From__��To�_��_ft.��u��s. ❑8ags MATERIAL From To ft. �]Yds. ❑Bags NEAREST KNOWN SOURCE OF CONTAMINATION C�� ft Q �� °,.,,%� feet `-R� direction r.... .: ::.:a�-:>�`,�iy,pe Well disinfected upon completion? r es r-��No ;.'4�,_ ,� C18Y gL"Sy SOft 1C� �O pUMP ; f �e�l �r�V ��t �O ��_��Not installed Date installed � � _r .) � � � Manufacturer's name - clay ��}1 �f� (�O 1 1 A Model Number ' HP ��; olts 1�LJ Length of drop pipe tt. Capacity g.p.m. �Llkl 'br� �l t l�l/ 1 GY Type:� Submersible r,_�LS.Turbine j]Reciprocating ,J Jet ❑ ABA DONED WELLS - Does property have any not in use and not sealed well(s)? �J Yes �� o VARIANCE Was a variance granted from the MDH for this well? � '�.Yes ' -o TN# WELL CONTRACTOR CERTIFICATION . This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. R�D�*�• rsG�� uL1�I� 4V�� InC• a dfvi.sion of DO[�.Stt�l�_�Tell Drillit� CA., IilC. 1591 Licensee Business Name Lic.or Reg.No. �-- ' � / 1/ ,, '. �. � .. .�! .�� -� / r e Representative Signata2` Certified Rep.No. Date 770002 `�� LOCAL COPY Name of ori��er — HE-01205-11(Rev.3/07)