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<br /> MINNESOTA UN/QUE WELL
<br /> ,WELL OI�!70RING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
<br /> ounty Name WELL AND BORING RECORD � ���16
<br /> Minnesota Statutes,Chapter 103/
<br /> To i Township No. Ranqe No. Section No. Frection WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> vi V�l.V �il7 �� J� J6 � �'/, ��L tt� �'
<br /> '� GPS DRILLING METHOD
<br /> � Lati[ude degrees minutes seconds
<br /> LOCATION: --- --- i-
<br /> t Longitude degrees minutes seconds :�Cable Tool . �.Driven f 1 Dug
<br /> �—- - _Auger }�'Rotary , ,Jetted
<br /> House Number,Street Name.City,and Zip Code of Well Location or Fire Number ' � -
<br /> [R! iJt�.�c L�� �� � VLi1[�[7 55359 DRILLING FLUID WELL HYDROFRACTURED? Li Yes �'�,'No -
<br /> Show exact location of welVboring in section grid with"X° Sketch map of well/boring location. ++�i+tlRl3t� �F
<br /> Showing property lines, From ft.To _ft.
<br />� N roads,buildings,and direction. USE �Domestic ❑Monitoring `��Heating/Cooling
<br /> � � � .,___ :
<br /> __;__.__i_. __,__ ___;_ �✓� �",� ,]Noncommunity PWS �� .Erniron.Bore Hole I�'Indushy/Commercial ��
<br /> �'.. ! ''�,Community PWS , .Irrigation j �Remedial
<br /> � ' -- --`-- ---`-' �.-.-�.� T . �-� '��. Dr Dewatering �,.�
<br /> � ,�. ` �_.Elevator - ��
<br /> e w ; , ; e 1{ � ����� CASING MATERIAL ve Shoe? ❑Na HOLE DIAM.
<br /> � �Y�
<br /> T � -` ��
<br /> ., � � ` � { � �Steel ,���.Threaded Welded
<br /> �ji + 7
<br /> , � t
<br /> '/Mile . ,r �_.., ....�/ , �
<br /> ,� ; ; � �� ( astic - --
<br /> PI �
<br /> .m -�- -- �--- --�- - : : : -. CASING I .
<br /> s
<br /> �f �' "" ��^' Diameter Weight Specifications
<br /> �1 Mile—� ;,%,� �in.to "��ft. Ibs./ft. '�fgin.to�ft.
<br /> 4. I r�ar
<br /> �� � � in.to____ ___..—ft. Ibs./ft. _ in.to��ft ��
<br /> PROPERTY OWNER'S NAME/COMPANY NAME --- �
<br /> R�vinlGeyle Talbot 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 /> Make From ft. To ft.
<br /> Type__ Diam.
<br /> SIoVGauze Length
<br /> Set between ft.and it. FITTINGS
<br /> " STATIC WATER LEVEL
<br /> Measured from
<br /> _�,�.___ft.;s�Below � 'Above land surface Date measured r�
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> ��_ ft.after � hrs.pumping g.p.m.
<br /> Well/boring owner's mailing address it 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 Boring ONLY)
<br /> GROUTING INFORMATION
<br /> we �i @' � !� 7t
<br /> Grout�m taerial_s� fy�t�ent '�ento�Concrete �. ,Other -
<br /> �� I�om_ To tt. �Yds. J Bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. �Yds. `Bags
<br /> MATERIAL From To ft. (�Yds. ]Bags
<br /> .. NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> Cla F)�� ! /.��`` feet �direction ��"�.�1-�.x-.-
<br /> type
<br /> - Well disinfected upon completion? {�Yes No t�i
<br /> �/CI�. b� � PUMP
<br />� r(�El$J�TL$�1 F,i� tg{� �„�/ �3,0 ` �Not installed Date installed 7�rl+��Z . .
<br /> Manufacturer's name e
<br /> ���
<br /> Model Numbe� HP�Volts
<br /> �-` -"'"t� Length of drop pipe__�� ft. Capacity g.p.m.
<br /> ���� �g��� 1*� Type:fy�Submersible ' ,LS.Turbine 'J Reciprocating �_'I�et ❑
<br /> L71 ABANDONED WELLS
<br /> gL��c�� ��$ � ��$�T/ Does property have any not in use and not sealed well(s)? i�Yes ,�No
<br /> !N1
<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 4�25.
<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.
<br /> Ibn Stodols �e2I Drillic� Cc,,, Inc. 1691
<br /> Licensee Business Name Lic.or Reg.No.
<br /> �-11 '
<br /> �
<br /> `f�ji_ �� �� a
<br /> rti� d epresent ive Signature Certified Rep.No. Date
<br /> LOCALCOPY 7 8 3 5 1 6 �� ��°d°�a --
<br /> Name of Driller
<br /> IC 140-0020
<br /> HE-01205-12(Rev.12/08)
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