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��,��.. WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AEND BORINIQUEOWELL ' County Name WELL AND BORING RECORD 7 8 9 9 2 7 ` �lennepin Minnesota Statutes,Chapter f037 .� Towry¢up�3�n�� Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED C�� U 118N 23i�T 26 STji St�f,, S►W ,, I39 h Sept 2p, 2U12 GPS DRILLING METHOD : LOCATION: Latitude degrees minutes seconds i Longitude degrees minutes seconds ��Cable Tool ❑Driven --- -- — — ❑Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number �;Other ' 1�80 LoYtg I.81ce Blvds LO1T� i�a,wa �S� v DRILLING FLUID WELL HYDROFRACTURED? Yes _ Na Show exact location of well/boring in section grid with"X:'�, � Sketch p of well/boring location. bf,+j�tOyjitC From ft.To ft. �/!1 �,,,...� �Showing property lines, N �(� roads,buildings,and direction. USE QC Domestic ❑Monitoring ❑Heating/Cooling ; __1___.�_____�____L_ ❑Noncommuniry PWS ❑Environ.Bore Hole ❑Industry/Commercial � �J Communiry PWS ❑Irrigation ❑Remedial ` --i-----;------F-----+— , ❑Elevator �]Dewatering ❑ � W � � � , E ��J v7�-'� CASING MATERIAL Drive Shoe? ❑Yes �]No HOLE DIAM. � T --- -- ----------- -- � ❑Steel �.�Threaded [_.]Welded '/z Miie �]Plastic ��1116 1 CASING S Diameter Weight Specifications i 1 Mile—i � in.To___ L3� fL Ibs./ft __ � • in.To � ft PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. • in.To13� ft Reith qande�mbranden in.To ft. Ibs./ft. in.To ft SCREEN OPEN HOLE � Property owner's mailing address if different than well location address indicated above. 1 i�1�0 �OS$ �S� B1V� Make .�aYCQ From ft. To ft. Ts(il1 Taa"�8 �4N 55356 Type____ ��_ _ Diam. , ( g � �� SIoVGauze �.8 Length�_ Set between 134__ft.and 139 ft. FITTINGS__ � mC}�C ; STATIC WATER LEVEL Measured from �r8.d.8 ft.�Below �]Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) Keith Yaadsahranden ft.after hrs.pumping 6� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ` j�]Pitless/adapter manufacturer �5��: Model �t�f [J Casing protection ❑12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) a' Matenal bent gran�om_ 8 To 75 ft. 6 [;Yds. �Bags Material_ From To ft. _ ❑Yds. ❑Bags HARDNESS OF Matenal From _To__ ft [�Yds. ❑Bags GEOLOGICALMATERIALS COLOFi MATERIAL FROM TO Drivencasingseal From To __ _ __Bags NEAREST KNOWN SOURCE OF CONTAMINATION+S� fr0ffi SBW@I� C18y tan Q 30 feet __ direction type CI.R�I g=�� 34 {y8 PUIMdPisinfected upon completion? Yes ❑No ❑Not installed Date installed �� /��,� clay & gravel r$�t�tBII � 7s Manufacturer's name C'V rr�L i ! Z.� sa.nd � gra.v�l. �1Yed 75 I39 Model Number HP � voics � � i J -^'� Length of drop pipe �� ft. Capacity _�g.p.m " Type:�� Submersible ❑L.S.Turbine [J 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 sheeG il needed. � REMARKS,ELEVATION,SOURCE OF DATA,etc. Steveas Drilling � Anv. Svc. I�C 2255 Licensee Business Name Lic.or Reg.No. � �!� �Sb 9 11/2�12 Cer i ied Representative Signature Certified Rep.No. Date LOCAL GGF�Y 7 8 9 9 2 7 Randy Johnson Name of Driller IC 140-0020 HE-01205-13(Rev.11/10) 1