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r r � . :�.. . . . _ . . . . . � MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. County Name WELL AND BORING CONSTRUCTION RECORD r �� n Minnesota Statutes,Chapter 10.3I �? � `��" � � Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED t�rono 117 23 � S,� SHj SW,, I 25 n IO-28-16 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑CableTool ❑Driven � � �� - �� ❑Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location I]Other �7 F$LYl.��e� Arr� 5539! DRILLINGFLUID WELLHYDROFRACTURED?,.�YAs' . No Show exact loc n of well/boring in section grid with"X" Sketch map of well/boring I af��pppppp111 �$t�� From ft.To___,. ft. �a�v i rp�.1 ��e Showing propert lin�, Vrr roads,buildin and di c . USE N k. �Domestic ❑Monitoring e g/ i � , , ,.s __;__ __;_._ ___�__ __,__ a �;�j ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ) ❑Community PWS ❑Irrigation ❑Remedial __�_____�_-- --;_-_;__ { �Elevator ❑Dewatering �J w ; ; ; ; e CASING MATERIAL Drive Shoe? HOLE DIAM. , , , , T ❑Yes �No --�-----;-----�-- --�- I ❑Steel ❑Threaded ❑Welded ; � ; ; ,1M ; ; ; ; Plastic ❑ _„" --�------�-- ---�- ie ' ; ; ; CASING � S Diameter Weight � Specifications e ` 4 ii5 h. Ibs./ft. Q in.To 5�. �1 Mile—� in.To -\ ''. �� PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. �in.To �"�"ft. ��r� �.�� in.To ft. Ibs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE 32U� �'art�or Lsne Make � � From ft. To ft. P� t �T 55447 Type stainles� steel Diam , � ' � � SIoVGauze �� Length �} ♦ 4 Set between ft.and ft. FITTING � � STATIC WATER LEVEL Measured from ft. Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) / I�� fl.afte� � hrs.pumping `�O g.p.m. WelUboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION t��-itQS��r ��PiUess/adapter manufacturer�M�4 Model ❑Casing protection �12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neabcement,concrete,cuttings,or other) Material t�ilt�l3��From � To lVft. ❑Yds. �Bags Matenal nstural f�l�_�To 115ft. �Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To Bags NEAREST KNOWN SOURCE OF CONTAMINATION Cj�� C�� '� �� feet /+� direction _ :—� �v,�_.� Well disinfected upon completion? �Yes ❑No , sacidy clay gcay i�m 1� 61 PUMP j c n ❑Not installed Date ins[alled_ �,��J O�l� �1� `� ��"� Manufacturer's name �[ici hrawn .i� IQ� �2S Model Number HP�Volts Length of drop pipe � ft. Capacity g.p.m Type: Submersible `�-'�LS.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. 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. Dor� Stodo2a We11 Drillin� Co,. Ir�. ib91 Licensee Business Name Lic.or Reg.No. `- - ,,/� .. �` �z-1�-�6 =t -� -- rfi Re esentative Si ature� Certified Rep.No. Date Rob Stod018 LOCAL COPY g 2 3 4 L�.4 -- — V' Name of Driller ID#52603 HE-01205-15(Rev.B/13)