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1` M/NNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> co„��Y Name WELL AND BORING RECORD -7 � � �� � <br /> Minnesota Statutes,Chapter 1037 <br /> Township Name Township No. Range No. Section No. Fraction WEWBORING DEPTH(completed) DATE WORK COMPLETED <br /> it. <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds �_�Cable Tool �Driven '�_�Dug <br /> Auger �+Rotary ,_Jetled <br /> House Number,SVeet Name,City,and Zip Code of Well Location or Fire Number �� <br /> DRILLING FLUID WELL HYDROFRACTURED? '�`:�Yes ��. o <br /> Show exact location of we/boring in section grid with"X:' Sketch map of well/boring lo ation. From ft.To ft. <br /> Showing propert lines, <br /> roads,buildings,and dir ction. USE — � <br /> nl �Domestic "Monitoring ��Heating/Cooling <br /> �' __L____:______L_ ___i__ " ❑Noncommunity PWS [�Environ.Bore Hole ❑Industry/Commercial <br /> .� j 1 L i- � ommu y WS ion _- emedial <br /> C nit P �frrigaf �l R <br /> : W , , , , E .�,�;��� �7x�� ASIN IAL aOe�n9 HOLEDIAM. <br /> ' ❑Elevator ❑Dew � _ �. <br /> T MATER Drive Sh ❑Yes [�Mo <br /> C G <br /> ' ' � � ' �,�" ' ���]Steel ❑Threaded �_J Welded <br /> ; , , , , Mile p — <br /> �h <br /> , , , , I lastic ❑ '' <br /> --,-----,-----�-- ---�-- 1 <br /> 'V ASING <br /> S � � Diameter Weight Specifications <br /> ..¢A` <br /> �i nniie� . __.�_in.to���ft. �_i�lbslft. ��� �_in.to_�ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. _IbsJft �in.to�.�ft. <br /> in.to ft. Ibs./ft. in.to ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN_ OPEN HOLE <br /> At�1 T,�� c� Make_�i�,.,sarw From ft. To ft. <br /> LVl � lisR� a7t Type Diam. �fw <br /> ��ta� PY' S.737� SIoUGauze _ Length <br /> $�tn:^���p�p St1�.•1�Zlc� Set between_. � .and ft. FITTING <br /> t� <br /> STATIC WATER L Measured from <br /> ft � elow ❑Above land surface Date measured <br />� � WELL OWNER'S NAME/COMPANY NAME PUMPING LpEVEL(below Iand surface) <br /> l�O ft.after ��� hrs.pumping � g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> Pitless/adapter manufacturer . Model <br /> '�.Casing Protection ,��'12 in.above grade <br /> '�At-grade(Environmental Well and 8oring ONLY) � f, <br /> GROUTING INFORMATION � <br /> Well grouted j�7es ' "'J <br /> ,J No <br /> Grout materials �J Neat cement�entonite ❑Concrete �,.;Other <br /> From�To�ft. �� ❑Yds. �(6ags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From__�To�'�;�") �:. �� j���i'._�gags <br /> MATERIAL From__ To ft. �]Yds. �ags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> � feet /i� direction - -� type <br /> Well disinfecled upon completion? � s ❑No <br /> � PUMP <br /> I�Not installed Date installed ���. ��i l � <br /> T Manufacturer's name <br /> � Model Number HP � Volts <br /> Length of drop pipe !��1_ � ft. Capacity g.p.m. <br /> Type:�,' Submersible �J LS.Turbine �]Reciprocating `__��,Jet L] <br /> ABA DONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? [;Yes ��; � No TN#_ <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. � <br /> � The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed. <br /> �� REMARKS,ELEVATION,SOURCE OF DATA,etc. � (�►�.J��$ ��� ��,li�yg '�a'0�• IQC• �6�1 <br /> ie«R �.r� <br /> � Licensee Business Name Lic.or Reg.No. I <br /> _ � <br /> � / f �� / x <br /> -- = ...--- _ . <br /> f Repres ntative SignatC�re Certified Rep.No. Date <br /> ' (� Q!llC�C �IbO�f.' <br /> a_ LOCAL COPY ��O U� � __ -- —--- --—--— <br /> Name of Driller <br /> IC 140-0020 <br /> HE-07205-11(Rev.3107) <br />