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! �` i i MINNESOTA UN/QUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. County Name WELL AND BORING RECORD Minnesota StaWtes,Chapter f037 � �a o a � Township Na e Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED ,� h. GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds I�Cable Tool ❑Driven _ Dug �.�Auger �otary ��Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � 3285 Grah� �ti21s lid� (3raio 5535 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �o Show exact location of well/boring in section grid with"X" Sketch map of well/boring I ation. From ft.To fl. - Showing proper M-�s N roads,buildings,and di elfdn. USE Domestic [�Monitoring [�Heating/Cooling � � `� __._____:__ ___�__ ___l_ r,, _J Noncommunity PWS ❑Erniron.Bore Hole ❑Industry/Commercial �\ �� ' �;Community PWS [_]Irrigation [.J Remedial --'-----;--- --`-----`-- ��' [��Dewater ',J v I I I I ..� t r.� — -- Elevator ing ; ; ; ; � - �� CASING MATERIAL Drive Shoe? '�-J Yes �`No HOLE DIAM. --�-----�-----�----.-- - y' T L]Steel � I Threaded !Welded , ; � , '/z Mile StiC � j � , I -'�' Pla --,--- --r----�-- ---:- 1 ;, CASING g � � " Diameter Weige�ht Specifications ? �—i Miie—� f��`� � in.to '�^^�' ft. ` Ib�� r��ih.to^�uft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./f�. "• in.to 4��ft. ��1� �(i �� in.to ft. Ibs./ft. in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE 15050 23rd Ae+e N Make From ft. To ft. Plymauth, MN SS447 Type stainle�$_ stl Diam. SIoUGauze_ �{}�� Length�� ♦ 4� Set between ft.and it. FITTINGS � � STATIC WATER LEVEL I� Measured from _ ft.i� .Below f`i Above land surface Date measured s WELL OWNER'S NAME/COMPANY NAME PUMPIftIG{{�VEL(bel w land surfaay q� LtJ[� d J ft.after hrs.pumping g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION � �Pitless/adapter manutacturer �. ��* �� Model �Casing Protection �.12 in.above grade [;At-grade(Environmental Well and Boring ONLY) - GROUTING INFORMATION Well grouted '_�_�,Yes ❑No Grout materials ❑Neat cement�Bentonite �:��-'.Concrete ❑Other From � To `� ft. �� a gs G E O L O G I C A L M A T E R I A L S C O L O R HARDNESS OF F R O M T O From MATERIAL From To ft. ❑Yds. '�_J Bags . ♦ NEAREST KNOWN SOURCE OF CONTAMINATION C18y �11� �r� (J t'�J �� feet - � direction *�- • type �1a� ��y lNird LD Z12 PUIMPsinfected upon completion? Yes ❑No � �v�� Lw� ��^ ��n ',_I Not installed Date installed `y �.l �� '� � ti'� Manufacturer's name fie�eea�i/clay �� (j f� j�� f/y\ Model Number ` " HP f � .�' Volts --,..� GtN / Length of drop pipe /�t/ ! ft. Capacity g.p.m. ��QY•�.�A �jC,av l•�rd �NV1 �f1'f Type:�' Submersible ❑LS.Turbine ❑Reciprocating ❑Jet [] ilU. , E l27 4llt! 6 L! ABAN ONED WELLS Does property have any not in use and not sealed well(s)? [��Yes �. o VARIANCE Was a variance granted from the MDH for this well? j �Yes No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The informalion contained in this report is Irue to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. tbn Stodola W�I1 Dral2ing Co., Inc. 1691 Licensee Business Name Lic.or Reg.No. � �� - l� - _ , � i- � J d epresentative Signatur�� Certified Rep.No. Date (� Jita Roh2so LOCAI C�JPY ��0 l.J O � Name of Driller IC 140-0020 HE-01205-11(Rev.3/07)