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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL ND. <br /> �o�,��Y Name � ¢ "= ;, WELL AND BORING RECORD 5 915 3 6 <br /> tic"'Ilfl'v'�i 1 Tl Minnesota Sfatutes Chapter f031 <br /> iownship Name Township No. Range No.�., ���eCpOn N,q.�,. ,Raction WELL DEPTH(completed) Date Work Completed <br /> JLOt1U 11F3 l.3 l;) i Yr ME �w 3`.31 " l���s.3d <br /> v. v. ��. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> �t��] t1 U il�c�r ��S Fa C7 Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger �Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". �� Sketch map of well location. � __ <br /> � / � Showing property lines, <br /> / " roads and butldmgs. DRILLING FLUID <br /> " :Ju��C ii@1—A <br /> � � � � <br /> _�- -�- -�- _�_ """""""""'�` USE ❑ Monitoring ❑ Heating/Cooling <br /> , � i � 1�Domestic <br /> • e rI '-. ! /�//5� ❑ Community PWS ❑ Indust /Commercial <br /> � � � i ' �! L 4 � ❑ Irrigation ❑ Noncommunity PWS O Remed al <br /> w e T ! ❑ Test well <br /> i i i i � ❑ Dewatering ❑ <br /> � �� � �r �2lMile r $ � CASING Drive Shoe? �Yes ❑ No HOLE DIAM. <br /> _i i _L_ _i_ � : IX Steel �.Threaded - ❑ Weltled <br /> i- - i- i i j <br /> , ❑ Plastic ❑ <br /> S �-----^ <br /> E-�-1 Mile-� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �'3 in.�o .��J C1 R. ___Ibs./tt. in.ta L'1 tt. <br /> :Iylaiid 1-IUTite?S __ in.to _ft. _roslt. �in s3�1 tt. <br /> Property owner's uiailing address if ditterent than well location address mdicated above. _ in.to tt. Ibs./ft. in.to tt. <br /> t.i� E3St. Li1,�CB .5�.�@'L'�t. SCREEN_ OPENHOLE <br /> e�ayzata, t�� �3�3Q1 Make_ from 3�y tt.to S�i ft. <br /> Type Dlam. <br /> SIoVGauze Length <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL � <br /> WELL OWNER'S NAME .�a1� tt.}�7 below ❑ above land suAace Date measured <br /> " PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. __ �.U d ft. after,_ .� _hrs.pumping �J g.p.m. <br /> WELL HEAD COMPLETION <br /> [�Pitless adapter manufacturer�n i t e w a ter M�e1 �J—J��! <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> - ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? '�Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material � Neat cement2Q7 eentonite ❑ Concrete ❑ High So�ids Bentonite <br /> MATERIAL from��_�to � ft. .� �7 yds. ❑ bags <br /> ��:>anciy �'�f3� �1C�'fA}Q ��U. y �g from to ft. ❑ yds. ❑ bags <br /> from to tt. ❑ yds. ❑ bags <br /> as��]� C��y I�11Y� I��GI� �(� �� NEARESTI�yQWNSOURCEOFCONTAMINAT�b� �e��j. <br /> �}�� feet My direction type <br /> �.;�a y � y e 11 o w a t 1 Ck y �$ �� Well disinfected upon completion? �7 Yes ❑ No <br /> PUMP <br /> .�and IIlX IIt�a. $2 1QFj ❑ Notinstalled Dateiry�t�ie 1�27�98 <br /> Manufacturer'sname �t'�axl��— <br /> Modelnumber lOP4GOLJ HP L voies <br /> �:1 a y 171 UE� A'1��•� Length of drop pipe � ft. Capacity L�I g.p.m. <br /> tlaL� 1 V� 1�0 Pressure Tank Capacity <br /> :;andy Cli�ly Liue IYi�L�. j.��} 1 16 Type�] Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> �7G ABANDONED WELLS <br /> �;j a y t31 L1@ �d• 1 /V �l.i Does property have any not in use and not sealed well(sj? ❑ Yes � No <br /> VARIANCE <br /> r.i r c��en r OC}�� c,r a ny� Was a variance granted from the MDH for this well? ❑ Yes $I No <br /> , re��7 course �ll :s3ti <br /> ::i3 nG` .S t V Sl� Wh 1-�.,1.,� WELL CONTRACTOR CERTIFICATION <br /> .����a i e Use a second ,�ed s��� ��� 3�, This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true ro the best of my knowledge. <br /> kES hi�ll �irillinc� L7276 <br /> Licensee Business Name Lic.or Reg.No. <br /> i <br /> / / ) <br /> ='._,.,.-;,�f_l���- � /.�.-.d..----- / :C` r' <br /> - Authonzed Representahve Signat�A Date <br /> Ran�y i�assiny 1J:�U/98 <br /> Name ol Driller Date <br /> LOCAL COPY 5 915 3 6 „E-0,2a�5�Re�.,,�5, <br />