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C 1 WELL LOCATION� MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUEWELL NO. County Name WELL AND BORING RECORD Minnesota Statutes, Chapter f037 ��' �� Township a e Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Comple[ed (� fl. i� i� ,� C' DRILLI G THOD LOCATION: LatiWde degrees minutes seconds �Cable Tool I, i Driven �-�Dug Longitude degrees minutes seconds � � - � �� Auger otary � �Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number U `J DRILLING FLUID WELL HYDROFRACTURED? ;]Yes o Show exact location of well in section grid ith"X". ��----�h map of we!I location. �$�ej,' FROM ft.TO � ft. �' howing property lines, N roads and buildings USE � ❑Monitoring ❑Heating/Cooling � i� omestic �Environ.Bore Hole ❑Industry/Commercial r � � �(y � '�Noncommunity PWS f��]Irrigation ❑Remedial ; I I I I _, _ I I I I / }�' ❑Community PWS ❑Dewatering ❑ --'----'-----`-- ---`-- W i i i i E� A IN Drive Shoe? ��,Yes �o OLE DIAM. .. S G — H --;--- --;--- -_�_ ___;_ � I Steel [Threaded ❑W Ided � 'h nniie lastic ' ' � r � 1 CASING DIAMETER WEIGHT � S ��Miie—� _._—�-_in.to �f1LA ft. �!.n� Ibs./ft. �in.to�ft. �RL� , _. in.to __,____ ft __, IbsJR. LI.. in,to�3/.Oft. PROPERTY OWNER'S NAME/COMPANY NAME �� 7�if . in.to.__ ft. Ibs./ft. in.to ft. ' �er Building Corp SCREEN OPEN HOLE Proper.y owner's mailing address if different than well location address indicated above. Make �� FROM ft. TO ft. 3435 Cty �r.l lUl Type----�� - Diam. �.2��t�RRiRA� A�+I 55345 SIoUGauze� 8 h/��8S a�l Length�� / Set between •�1V ft.and__. ft. FITTINGS+i� '�''i t STATIC WAT EL � � 11� ft elow �;above land surface Date measured TJRl�4 PUMPING LEVEL(below land surface) �� WELL OWNER'S NAME/COMPANY NAME �� /� . ...._4,1_�ft.after Z hrs.pumping 4SJ g.p.m. WELL HEAD COMPLETION • .9� t—� . Well owner's mailing address if different than property owners address indicated above. .Pitless adapter manufacturer v-�J�� ..-J.SLr�a.}'��i.�"filAdel � �� �Casing Protection �12 in.above grade ❑At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATION � � Well grouted es U No . Grout material J Neat cement ��Bento�ni/te�;J Concrete igh Solids Benronite �� from g�Q to ./7�t1 ft. 3 �yds.t�ags � from .71J to ZyIJ__ft. ��1 j��1�ir'bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft []yds. jJ bags MATERIAL NEAREST KNOWN SOURCE OF CONTAMINATION (�`la5/ yE.aI��T $�ft � 26 �� feet _direction '''��- type � Well disinfected upon completion es ❑No � Clay �T.$�T S'�O1C Z� 1W PUMP f,. � �Not installed Date installed �`C? � ` �� ;' $�'j(� c+�att f�f C 1� 'i� Manufacturer's name .,f�"r��_a3---i�-r"S"'.� �� d J r^�, Model number HP_.-.,�� Volts �� ..J �. C�yJ r�lC� gr8'y �.f(� y.�/ �,yp Length of drop pipe � �� ft. Capacity g.p.m. Type:�. � ubmersible ❑LS.Turbine [__]Reciprocating �;Jet [j sarxi/gravel br�[� �� 6�8 ABA ONED WELLS Does property have any not in use and not sealed well(s) I I Yes � o .� VARIANCE Was a variance granted from the MDH for this well? ��Yes o 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 a REMARKS,ELEVATION,SOURCE OF DATA,etc. a�V[; Stodola �lI Drilling Co�r� �• G717L �. Licensee Business Name Lic.or Reg.No. : o r se t ive igna(we Date C�l.�t I�'IOdC� 5'��i Name ol Driller LOCAL COPY 7 � '� �� Q, - HE-01205-08(Rev.5/02) _� IC 140-0020