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�_ MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> � CountyName WELL AND BORING RECORD � � ��� � .��� �-. <br /> Minnesota Statutes,Chapter 1037 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br />° �� I25 " 12-5-D8 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes __ seconds <br />� Longitude degrees minutes seconds �_;Cable Tool �� .Driven I ;Dug <br /> [_J Auger !lyFiotary I.,Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number � �, ' ` <br /> DRIEtING FLUID WELL HYDROFRACTURED? [�Yes o <br /> Show exact location of well/boring in section grid ith"X" Sketch map of well/boring location. ���� rom ft.To ft. <br /> Showing property lines, <br /> N r.�— roads,buildings,and direction. USE �omestic ,]Monitorin <br /> ' g �_]Heating/Cooling <br /> __1___ __�____L__ ___i__ �� .^Noncommuniry PWS U Environ.Bore Hole f�Industry/Commercial <br /> � �, -�.Community PWS ❑Irrigation ❑Remedial <br /> --'--- --'------`-----'-- � �_��.Elevator ❑Dewatering ❑ <br /> W , , , , E T ASIN RIA ve Shoe� ' k�No OLE DIAM. <br /> C G MATE L Yes H <br /> --�-- --�----�-- ---<-- ,�_ ' `- -- <br /> G Dri � <br /> I � / _Steel r Threaded ❑Welded <br /> 'h M'ie ��r ,.,....� jJ l �plastic r <br /> 1 �,/� t � (y CASING <br /> � � S � � � Diameter * Weight Specifications <br />��. �1 Mile—� � in.to 1�� ft ��'" Ibs./ft. �� � in.to ''ft. <br />. PROPERTY OWNER'S NAME/COMPANY NAME in.to _ft. IbsJft. �in.t�ft. <br /> ���h q�� a�j'j in.to ft. IbsJft. in.ta ft. <br /> Property owner's mailing address if drfferent than well location address indicated above. <br /> SCREEN OPEN HOLE <br /> � $� $� Make � From ft. To ft. <br /> Type •��.�t...... ..�t Diam. N <br /> �G aICZZAa—�LT--- <br /> SIoUGauze Length_ <br /> Set between �ft.an FITTINGS�� <br /> STATIC WATER L Measured from <br /> _�___ft.�. �' elow I,� ��Above land surface Date measured �+��� <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after 1 hrs.pumping ��g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �, • <br /> �pitless/adapter manufacturer ...�.���� ..��>�--����a��'�RAodel <br /> !J Casing Protection '��C72 in.above grade <br /> (�At-grade(Environmental Well and Boring ONLY) � <br /> GROUTING INFORMATION <br /> Well grouted �,14'es [No <br />, Grout materials J Neat cement i�entonite ❑Concrete ❑Other <br /> From_�_To__�_ft. _�___ ❑Yds. ��'Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_��_To_��ft.����l�is. ❑Bags <br /> MATERIAL From To ft. ❑Yds. ❑Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINPT�^N ,/, <br /> caly/gravel bro�wn seft t� 15 z� � �r {' <br /> � feet _ _. direction �""�"� —����'�}yp <br /> (�Well disinfected upon completion? �.'Sles []No ��y„r��.„�-- <br /> �y ��y �� �� j�PUMP <br /> �3���$�� ��$v `_,�� � 12S U Not installed Date installed �::"` ��j%� J --� <br /> e3i�E3CE � �xlCil # <br /> Manufacturer'sname t�..rv�.� .+�..s�"'�+�^ """ <br /> Model Number � HP_�Volts + �� <br /> Length of drop pipe>�� �p��.�G.. fl. Capacity g.p.m. <br /> Type:f ubmersible I`,.I LS.Turbine (1 Reciprocating ❑Jet ❑ <br /> ABAN ONED WELLS <br /> Does properry have any not in use and not sealed well(s)? �]Yes �,a}elQo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? � '��Yes � o 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 repor�is true to the best of my knowledge. <br /> Use a second sheet,il needed. !� rL ,t 1 T 3� 2 j p <br /> �:� REMARKS,ELEVATION,SOURCE OF DATA,etc. R�C,�S• �aCZ� DC11Z1T�j CO�� 1CIC• � CLLViH1OCI QS <br /> D�#StOd0�8 W�LI 1?C�II�.tl}�, CQ,• �I1C. If?�� <br /> Licensee Business Name Lic.or Reg.No. <br /> ., <br /> f . <br /> f-`'` /..�' /� �� <br /> C � e ignatUre _ -- c.--'�-Certified Rep.No. Date <br /> 7 6 5 �2 2 �c �c�rre <br /> LOCAL CdPY Name of Driller <br /> IC 140-0020 HE01205-11(Rev.3/07) <br />