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.:;_a—. . �: _ . . _.._.. _._ .r _ ,.__ .�.__._._; . . __, �_ . . . .. _ ,. . _ .� ... _ .,. WELi OR BOR7NG LOCATION MINNESOTA UNIQUE WELL MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. County Name WELL AND BORING CONSTRUCTION RECORD S 18�21 Minnesota Statutes,Chapter 103I Township N• e Township No. Range No. Section No. Fraction WELUBORING DEPTH(compieted) DATE WORK COMPLETED ,� 138 h. 3-19- GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool �❑Driven House Number,Street Name,City,and ZIP Code of Well Location .❑ahe r �Rotary ocT o 5 2 0�� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes � No Show exact ocation o we/boring in sectio g id with"X:' Sketch map of well/boring location. �c �$C From_ .��R�NO ft. Showing property lines. N �/ r �..�bifiidh�qs,and direction. USE �Domestic ❑Monitoring [!Heating/Cooling ' , � , � N- �.�.-�. �.- � � � � �'�' ❑Noncommunity P S ❑Environ.Bore Hole ❑Industry/Commercial W i -- -- ---- -- --- - �� __ � " ? ; ; ,� � ❑Community PWS ❑Irrigation emedial r-,R f --�-- --;-----}-----�-- ,r�¢ []Elevator ❑Dewatering [� . � I W ; ; ; i E� CASING MATERIAL D ive Shoe? ❑Yes �lo HOLE DIAM. f ' ' f ,/z Mile ❑SI2StiC � ' -- -- -- -------- " ��Threaded ❑Welded ------------ ---�----:-- 1 CAS W G � � S � Diameter ^ Weight Specifications ��M�te� ��1��'�� in.Ta �G� ft. Ibs./ft. � in.To � PROPERTY OWNER'S NAME/COMPANY NAME in.Ta ft. Ibs./ft. �in.To 13 . in.To ft. Ibs./ft. in.To ft. ro e y ow r's mai ing a dress i(ditferent than well location address indicated above. SCREEN OPEN HOLE Make �n From ft. To ft. 18215 45th aDe fi�, Ste D Type stainiess �teel Diam. Lll�p�t[!� i'si� Sj.7[,��] SIoUGauze �a�,Q �Length t}� ♦ �}! J.�,.�.� ' Set between tt.and ft. FITTINGS � 1 STATIC WATER LEVEL Measured from ft. elow ,']Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ft.after_, hrs.pumping g.p.m. ` Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �Pitless/adapter manufacturer��E�,��e� Model ❑Casing protection �12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT W FORMATION(specify bentonite,cemenFsand,neat-cement,concrete,cuttings,or other) Material �tV17it�rom 11 To SQ n. 3 �Yds. �ags Material n$�r$Z ��,_ �To 129 ft. �Yds. �Bags HARDNESS OF Material From To ft. ❑Yds. [�Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Dnvencasingseal From __To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION ��7 feet _.i' direction '' � type Well disinfected upon completion? .Yes J No PUMP �J Not installed Date installed "'+IS-I�i Manufacturer's name Model Number HP 1.J Volts Length of drop pipe 1't7 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 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. � REMARKS,ELEVATION,SOURCE OF DATA,eta � , � J Licensee Business Name _��,/' � ic.or Reg.No. `�'�� :r�f� ` �-' � �Z7�I�i "rtified epresentative Signature Certified Rep.No. Date " Q Adt3 Stfl(�018 �-�CP`�-C'�PY 8 1 Q o� � Name of Driller ID#52603 HE-01205-15(Rev.8/13) r�:,