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r � MINNESOTA UNIQUE WELL
<br /> WELL OR BORWG LOCATION
<br /> MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. `
<br /> County Name WELL AND BORING RECORD .
<br /> , `' i�� �� f i
<br /> �;pni�..a in Minnesota Statutes,Chapter 1037 ^ �• ��
<br /> p � :. _fr ,� ��
<br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> �Conc} 127 23 �5 �J "��,�h�'; ,� .� n.
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes __ seconds
<br /> Longitude degrees _ minutes seconds
<br /> �,_,���Cable Tool ❑Driven
<br /> [_]Auger �otary
<br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other �
<br /> �4�5 ;"�..Lr�•ii �.C3�� �r�1'� 55355 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �,�No
<br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. t?�t n[ From ft.To ft.
<br /> Showing property lines,
<br /> ; N roads buildir�qs,a�d direction. USE ` '
<br /> ` /:', , ; . . ;.A I�Domestic ❑Monitoring 1-J Heating/Cooling
<br /> ; , 'T .�.... '
<br /> ._
<br /> _.__ ___ ___�_ _.__ ❑Noncommunity PWS ❑Environ.Bore Hole �]Industry/Commercial ,
<br /> � v "`-- "� � ❑Communiry PWS ❑Irrigation ❑Remedial
<br /> --'-----,--- ---`-----'--
<br /> ❑Elevator ❑Dewatering ❑
<br /> � w , , , ; E 4' 4`� CASING MATERIAL Drive Shoe? ��Yes �lo HOLE DIAM.
<br /> , , , T ,>,- . _�___�.__.
<br /> ' ' � -` � �,]Steel ❑Threaded ❑Welded
<br /> .. , , , , Mile
<br /> '/ r
<br /> �� --�-----�--- ---%- ' I� .�lastic U ..
<br /> 1 CASING
<br /> S � . ,��V . Diameter Weight Specifications
<br /> �iMne� _� in.To __7`��7 ft. Ibs./ft. � in.To_ �)�At
<br /> �`� 1
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft Ibs./ft. ('� in.To �s�t
<br /> t.q j1�E,, i��� in.Ta ft. Ibs./ft. in.To n
<br /> Property owner's mailing address if different than well location address indicated above.
<br /> SCREEN OPEN HOLE
<br /> q�� � Make 0� ��n1 1 __ From_ ft. To ft.
<br /> Type__.._ Stc'�.�.Lil�$!g $�i Diam. _
<br /> t
<br /> SIoUGauze ���,� Length_�j.� + (}��
<br /> Set between ft.and ft. FITTINGS „ i
<br /> a — �
<br /> STATIC WATER LEVEL
<br /> 1�n Measured from _
<br /> � _� ft.�Below �]Above land surface Date measured
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> ?� ft.after 3 hrs.pumping_ 2� g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �t�ater
<br /> PiUess/adapter manufacturer_____ Model ___
<br /> �,'Casing protection _____ s[�12 in.above grade
<br /> ❑At-grade []Well House []Hand Pump
<br /> GROUTWG MFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
<br /> Material_ t7C[iCOTI�C�rom V To�ft. � ❑Yds. (x'Bags
<br /> MaterialCli#t�_,�1 f�r��_SO To_��ft. ❑Yds. ❑Bags
<br /> HARDNESS OF Matenal From To _ft. ❑Yds. I..�Bags
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
<br /> Driven casing seal From_____To Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> to�sail black soft � 2 , > �
<br /> _feet __ direction � � `-- type
<br /> .._ '^.' ; �
<br /> y +� Well disinfected upon completion? es U No
<br /> CIB� j/�1�.CX� ��Uifl 2 �.J PUMP
<br /> t ❑Not installed Date installed � £3-13-14
<br /> sandy ctay �ray mecii3.�n 33 �J Manufacturer's name �C������ _
<br /> ��8�/���V�� �C�� �i� �� ��� Model Number HP__1_Volts Z�
<br /> f � 16� _ft. Capacity g.p.m
<br /> Length of drop pipe
<br /> �c'����cavel �'jy� (�Q(,�,�„j„�(� 1�}� ��(� Type:j�ubmersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑
<br /> ABANDONED WELLS
<br /> �nCiy C i$� r� 1��.��) 1� I�7 Does property have any not in use and not sealed well(s)? ❑Yes o
<br /> VARIANCE
<br /> cY$C�1 t'C� 1��i� 1C)'7 21 C� Was a variance granted from the MDH for this well? ❑Yes �No TN#
<br /> , WELL CONTRACTOR CERTIFICATION
<br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
<br /> The information contained in this report is true to the best of my knowledge.
<br /> Use a second sheet,if needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA.etc. -
<br /> ±�r.�n Stodola ��ell �illin�� Co . Iczc. 1Ei92
<br /> Licensee Business Name Lic.or Reg.No.
<br /> �r r---'
<br /> '`� r ������` 10�'7�11€
<br /> , ; . , ' . . � ..
<br /> Certiffed Representative Signature Certified Rep.No. Date
<br /> ROk� Stodola
<br /> a�OCAL COPY ' ' � � --
<br /> �.> � - Name of Driller
<br /> IC 740-0020 HE-01205-14(Rev.5/12)
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