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� MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. County Name WELL AND BORING CONSTRUCTION RECORD 81 O H �J 7 Hennepin Minnesota Statutes,Chapier 103I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED �rorw 118 23 30 SF Nt� SE, 13� K 1`22-. S �� GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD �"" r' y-^�.�" Latitude Longitude ❑Cable Tool ��, ',Driven � ;J Auger 'hrl'Rotary � House Number,Street Name,City,and ZIP Code of Well LocatioCn n Other �� ' IOUS ?iunt rtl� Rd� D�Q� �J356 � DRILLING FLUID WELL HYDROFRACTURED? �� Ye o �� Show exact location of well/boring in section grid�wiflf' ° Sketch map of well/boring location. ��tQr From "�','-1i.?e�a� tt. ;_ J�� Showing property lines. - N �y f roads,buildings,and direction. USE �Domestic ! j Monitoring '�� ' I—J Heating/Cooling � � � � ,.,j:?°� j '�, �;Noncommunity PWS �_'Environ.Bore Hole '��Industry/Commercial --'--- ---'--- ---`-----`— �' �,�� Community PWS ��Irrigation ❑Remedial --�--- ------ ---=----�-- ,, � levator [�Dewatering ❑ ____ w ; ; ; ; E ��„-��1,' ASIN Drive Shoe? ��Yes �No OLE DIAM. !`' ❑E T C G MATERIAL H --�--- --�--- --�----%-- �j �Jl Steel [;Threaded Lj Welded --�--- --�--- --�--�—:— I de - — - 'M y + + ,�Plastic [� _ 1 1 �4'� CASING S � � t f�>.,�" Diameter Weight Specifications i 1 Mile� l��`� V''~� � in.To �� ft. _____Ibs./ft. _ � in.To ��ft. . -�.f�" � �� PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. __ Ibs./ft. __ _ __in.To____ft. Steve/Kathleen Pecsian in.Ta ft Ibs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN�y��___ OPEN HOLE JVtlk Make _—. From_ ft. To_ ft. Type__s�_ n ess $ �e. Diam. Slot/Gauze �111 V __Length_�� Set between 13� _ ft.and__��fL FITTINGS�_�� STATIC WATER LEVEL 7n Measured from � � ,ft.`-,�Below ❑Above land surface Date measured� ' WELL OWNER'S NAMEiCOMPANY NAME P;M�ICG LEVEL(below land surtace) � 'n i G 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/adapier manutacturer_�+�}'►itE+LJ3CEar Model �.�J Casing prolection _ �2 in.above grade f-1 At-grade �.�Well House �.�i Hand Pump GROUT INFLO—RMATION lspecify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material_ '-KintQnitrrom �j To �`� ft. �, ,.�_ ❑Yds. '�Bags Material_��tu[a f�„I__5� ro_ 130 n. L;vd5. �-'�;sa95 HARDNESS OF Matenal_____ From_ __ __To ft. � ❑Yds. �__I Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From_ ____To _ Bags NEAREST KNOWN SOURCE OF CONTAMINATION � topsoil black i�n 0 2 M �t n t _ feet _._ � direction RpS)f�[� type �t_�_��-- $$Illl� Cl$� brown �� 7 �+� Well disinfected upon completion? �'es '_�No G PUMP 7 1 !� ��Not installed Date installed_ �-2h'15 Clay d�8� �1� �� Manufacturer'sname___�I'�1. � � sa��L+la� hrQ�•� i1.E71 75 (�C Model Number __ ___ _HP 1 s J Volts_GJU J 1 Length of drop pipe jo�_ ___ft. Capacity g.p.m. 9��d!ClBy re� ,.edium .QiS �,�,� Type:�� Submersible '� �L5.Turbine �]Reciprocating ❑Jet �J. ABANDONED WELLS sa� re�. soft 1.l S 13� Does properry have any not in use and not sealed well(s)? ��' 1 Yes o VARIANCE Was a variance granted from the MDH for this well? iJ Yes � � o TN# WELL CONTFACTOR CEFTIFICATION I This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. I The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA.etc. Aoc� _Stodola Well Arillin��Co�_Inc. 1691 ___ _ Licensee Business Name ,✓`� Lic.or Reg.No. .%� -----',-, �' _ _,l ��--- �- �ie e esentative Signature � Certified Rep.No. Date �10�5 7 ��h sr�Qz� I LOCAL COPY _— _ _--- � Name of Driller � � r;;140-0020 HE01205-15(Rev.8/13)