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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CounlyName WELL AND BORING RECORD 5 915 31 H"1:1�' 1 il Minnesota Statutes Chapter 703/ Township Name Township No. Range No. Sedion No. Fraction WELL DEPTH(completed) Date Work Completed M��iaa 11� 23 L5 w NE SW s�0 " �,. ,. �,. 11/10/9 7 House Number,Street Name,City,and Zlp Code ot Well Location or Fire Number DRILIING METHOD C C7 Cable Tool ❑ Driven ❑ Dug ��J riunt,�r �dSS f7 Auger �1 Rotary ❑ Jetled Show exact location of well in section gnd with"X". Sketch map of well Ixation. f 7 ---------_— — -------- Showing property lines, �y ��, i'� roads and bwldings. DRILLING FLUID N 1 v , � � � , �uper �e1-x � � -;- -,- USE ❑ Monitoring ❑ Hea6ng/Cooling $l Domestic ❑ Communit PWS _i_ _a_ _i_ _i_ ��T y� ❑ Irnga6on Y ❑ Industry/Commercial i i i � ❑ Noncommunity PWS ❑ Remedial w e� . � \ ❑ Test well i � � i ❑ Dewatering ❑ i -, r r '/ZM1e �� """`�`y CASING Drive Shoe? �1 Yes ❑ No HOLE DIAM. i i i i ,�. i Xl Steel ❑ Threaded ❑ Welded -,- - ,- -� - -� 1 � _ �, _ S � �w- � ❑ Plastic ❑ �-1 M�le-� ��' CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME ' y�, � in.to � � tt. Ibs./fl. in.to��Mt. J lana �1LJl2k�S in.to ft _�bs./ft;3 ��.to�_y(jt. Property owner's mailing address if different than well location address indicated above. in.to _ft. Ibs./ft. in.to fl. l39 �.`.• Ld:{'{.'� .S�ir4��. SCREEN OPENHOLE7� /_ /� ��1�rl.d�.d� MN �5.s91 Make from �JaFt R.to�LJ _fl. Type Diam. SIOVGauze . _ Length Set between ft.and tt. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME 1�V ft. CXbelow ❑ above land surtace Date measured PUMPING LEVEL(below land surface) Well owner's mailmg address if different than property owner's address indicated above. _ �_Q(�___ft. after _3 _hrs.pumping ,iy�_g.p.m. WELL HEAD COMPLETION J�PitlessadaptermanufacWrer Y�ihi tewater Model r��5�� ❑ Casing Protection ❑ 72 in.above grede ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? ,$1 Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout�vtateria� $� Neat cemem ❑ Bentonite G Concrete ❑ tigh So�ids Bentonite MATERIAL from 3�5 to � ft. �3 ]Q] yds ❑ bags sand� clay r�ra�rn mea. a � from �o n o yds ❑ bags from to tt. ❑ yds. ❑ bags Sal�d b �ZaV-Z.L �JX�I�+Ll �I��(• 5 j� NEARESTKNOWNSOURCEOFCONTAMINATION t3� feet �d�t direction:'��r i+jciLb�e Well disinfected upon completion? C�Yes ❑ No aanc�y clay blu� m�d. 3C3 7t3 PUMP �eu• ` ❑ Not installed Date installed_____._�L/19/�Z—___ _ saiiuy 41ay y�llot� 11are�� •�$ 97 Manutacturer'sname 51'.e�l��Llt� Model number�� ? � HP��_ Volts l.j� �l,1 l�L j�l�(Y•� Length of drop pipe 1�7 __ ft. Capacity g.p.m. BdY1L3Y clay r$ l�rf� t3", �ai PressureTankCapacity__ l�� __ Type�T7 Submersible ❑ LS.Turbine O Reciprocating ❑ Jet ❑ _ sand�r elay 2ight Sd�t ��1 ��g ABANDONEDWELLS `u'Y1dl� raek ��X Does propeAy have any not in use and not sealed well(s)? ❑ Yes .�7 No �ellow hara 318 334 VARIANCE Y'Q(�K ,Y is�`�.�Q� hard �J 4 340 Was a variance granted from the MDH for this well? ❑ Yes �°Q No WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. RE5 W�I1 Drilliny i7"l76 Licensee Business Name � Lic.or Reg.No. .,�' i � / / �.�''�,.��7��-X �,�f'�.� �-��/ 7/i � Authorized Representative Signature Da e „a�� E a,;::, �obert E. Stodr�la� 3r. 1"l/i7/97 {� , .f. Name ol Driller Date . . . ; I.00AI.COPY 5 915 31 HE-01205-05(Rev.1/95)