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c, WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUEWEII NO. County Name WELL AND BORING RECORD , � �'2 � in Minnesota Statutes,Chapter f031 � „J_ ��"�� `""' , � Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed � 4s�no lI7 23 t�i �,, �� , " _ � GPS DRILLING METHOD - LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds �Cable Tool ' J Driven _ Dug ��Auger �Rotary ,Jetted - House Number,Street Name,City,and Zip Code of Well Location or Fire Number � �-- 31L� r� ��C Ocon� 5S356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well in section grid with"X". Sketch map of well location. �t�r FROM ft.TO ft. Showing properry lines, N roads and buildings USE � �Monitoring ❑Heating/Cooling = � � � � �Domestic ��'Environ.Bore Hole ❑IndusVy/Commercial � � --'--- —'--- --`-- ---`- `� ;J Noncommunity PWS �—]Irrigation ]Remedial � I I I ' ❑Community PWS ❑Dewatering '] � , J CASING Drive Shoe? ��Yes ��. N HOLE DIAM. W - -- - - E T - _ ° ❑Steel ❑Threaded ^'��We�d 'h nniie �� Plastic � �� --�-- —�-----�-- ---%-- 1 '� ___ 5 CASING DIAMETER WEIGHT I I S I I �_.✓� ' _.._ `�� �. `� _�__in.to��ft. '�� Ibs./ft �_in.to '.. ,� �—i nn�ie—� �,� � _ in.to ft. _ .____ Ibs./ft �in.to_��. =� PROPERTY OWNER'S NAME/COMPANY NAME in.to_. tt. Ibs./ft. in.to ft. Jeff Nelscm C.anstt�ctfon SCREEN y OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make �� J"`��i FROM tt. TO ft. 515 lst A�re �t TYpe ��.�1��$__$tl Diam. _. .--- ,. .. ;�nt�' � QGnLA SIoUGauze ___�rn n__ Length�� .�.�,�� J.)IJ�K) Set between ft.and ft. FITTINGS �► M STATIC WATER LEVEL �� ft. below U above land surface Date measured 12�� PUMPING LEVEL(below land surface) `�� -:�WELL OWNER'S NAME/COMPANY NAME � � . � �� n f ft.after ` hrs.pumping � g.p.m. WELL HEAD COMPLETION f.�.s '� Well owner's mailing address if different than property owners address indicated above. �Pitless adapter manufacturer w`�t�te� Model _Casing Protection ___ �j 12 in.above grade ��,J At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATION Well grouted �Yes [No Grout material ❑Neat cemeM �_J Bentonite ;]Concrete�i High Solids Bentonite from�.to�ft � � �yds. �bags from_�to��#_ft. �� jcjMs� r]bags HARDNESS OF Y:ill GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from to ft. 'I yds. ❑bags NEAREST KNOWN SOURCE OF CONTAMINATION la ell� f _ � ,� feet direction � � 4 rype Well disinfected upon completion Yes ❑No \ C18. � p PUMP . j '�, �Not installed Date installed �`�" " ' t��.�� Manufacturer's name__ �y�-tf�tj�� Model number li�Li C.1Ciat1T� HP�Volts LJl! Length of drop pipe �Zvt T� ft Capacity g.p.m. Type:�Submersible �:J�L.S.Turbine ;f-�Reciprocating ❑Jet [_] 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? [Yes No 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 ihe best of my knowledge. t Use a second sheet,ii needed TM_ REMARKS,E�/��jION,SOURCE OF DATA,etc. sM! �taioia Well Dcilli.ng Co,. lj�• 2��, `��A Licensee Business Name Lic.or Reg.No. :��R ��F�, �._.. � � .� � ''- 1-28-�'}S ��O^ �oOC A h �ed Representative Sig/raiure Date ✓ r �� � -- � .�� LOCAL COPY �� (;� Q � 5 Name of Driller �.,t <1 HE-01205-OB(Rev.5/02) IC 740-0020