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...�.:,R,j ,. ��r,��t'��.!!',t� t��1.1 ' . , . f _ � ' WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIc7UE WELL NO. � County Name WELL AND BORING RECORD Minnesota Statufes, Chapter f037 7� � � � � To Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Ii7 23 09 �� I28 " �-11-04 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds ��Cable Tool ��Driven Dug _ — �Auger j�Rotary �]Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number - � f' . � IIlRC � Oicocio 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well in section grid with"X". Sketch map of well location. �n�� FROM tt.TO ft. Showing property lines, N roads and buildings USE ` ❑Monitoring []Heating/Cooling � � � � �j Domestic Ty �Environ.Bore Hole ❑Industry/Commercial � --'-----'------`—--`- � 9 ❑ , � I j j j � Noncommuni PWS Irri ation Remedial � W � ; j j E �� CASING�I Community PWS DjIDeShoe?n9❑Yes No HOLE DIAM. �� � , � , T s _.�.. _ -- -- - - --- -- --- _J Steel [J Threaded I� elded .. --,--- - �- - ' .-- - �.; I ; � I I Mi�e , ('ti4 E.�� ,1 � �' �u� � �Plastic ❑ � --�--- --�-- --•- � �. _ � � S � � CASING DIAMETER WEIGHT F--i nniie—� �in.to 120 ft. 4a Vl Ibs./ft. v in.to �ft. in.to ft. __ Ibs./ft. �in.to��+tt. PROPERTY OWNER'S NAME/COMPANY NAME in.to_,_ ft Ibs./ft. in.to ft. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make_.�� . ._ FROM ft. TO ft. - � 8� a� TYPe—��—��-.. Diam._�— —_.. _ SIoVGauze____ � _ Length L�_�� __ Set between ft.and_ fL FITTINGS STATIC WATER �,rf � i below �]above land surface Date measured 5—i1—Q4 PUMPING LEVEL(b_ow land surfaA) � ' WELL OWNER'S NAME/COMPANY NAME �;p ` - [7 ft.after hrs.pumping g.p.m. �HEAD COMPLETION 1. �� Well owner's mailing address if differen�,t�.��Q�er�s address indicated above. Pitless adapter manufacturer �L��t�� Model ��' iV Casing Protection �2 in.above grade ❑At-grade(Environmental Wells and Boring ONLY) �C�I 6 �};1(1� GROUTING INFORMATION . ^ 4 e11tj Well grouted �Yes �� No CITY OF pR Grout material ,�Neat cement ❑Bentonite ❑Concrete�High Solids Bentonite D�O from�to.__�ft � ' 'yds. I� ags from�toyy�Rj��jj��,�s. �ags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. ❑bags MATERIAL ❑yds. NEAREST KNOWN SOURCE OF CONTAMINATION P'� — � ` Q t �.l feet �� direction � � type � 1 r� Well disinfected upan completion (_,-1 Yes ��No PUMP mediu�a k 80 � S-1I-04 �Not installed Date installed t !!11 r}L ManufactureYs name CRJ 7� +1�lA Model number __ HP__�_��Volts �.�l �� (�� '�� Length of drop pipe C7�i ft. Capacity g.p.m. Type: Submersible ❑LS.Turbine I�Reciprocating jJ�Jet [� ABA DONED 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? ❑Ves 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 the best of my knowledge. Use a second sheet,i1 needed ` REMARKS,ELEVATION,SOURCE OF DATA,etc. �(i SCU42O�� NCli ��1� LV�• 1t�{,;a Z/l� -- Licensee Business Na e Lic.or Reg.No. : .. . ; , .._.....�. ,. .r�� C—*p�� --"'"�� TiL7—l!Y i ri e resentative Signature Date � �� - � � � � � � Name oi Driller LOCAL COPY HE-01205-OB(Rev.S/02) IC 140-0020