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