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, � ., ,. _ .� ,:. . ,. � MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. - CountyName WELL AND BORING RECORD 7 � 5 516 Hennep in Minnesota Statutes,Chapter 1037 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED tkoa�o 118 23 35 SE S� �, 1�0 n 12-6-{38 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds ,_ _ Longitude degrees minutes seconds :._i Cable Tool f�Driven �,Dug --- �Auger j�Rotary =.�Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �--� / �,�� jj� ��s �d(p ��I DRILLING FLUID WELL HYDROFRACTURED? �I Yes o Show exact location of welUboring in section grid with"X" Sketch map of well/boring loca[ion. �t��e From ft.To ft. Showing property lines, — N roads,buildings,and direction. USE ��Domestic (�Monitoring ��Heating/Cooling ' y '�— ; '�Community PWSWS �`-'Environ.Bore Hole �Industry/Commercial � �,,,,� _ ',]Irrigation �,�Remedial � --1-----'------5-----'-- t �` � j Elevator ��Dewatering �� ... �' ; ; ; ; E T ASIN Dri ThSho�e tl �,J Yes `�`N�o OLE DIAM.-- � � C G MATERIAL H � ------ ---------�-- ---*-- � 'a �(�. �M� J '_�'Steel �_I rea e ��Welde --�--- --�--- --�-- --�-- 1 Plastic �] CASING I g � Diameter Weight Specifications �1Mile—� �� -Y,.�-e H��- �in.to�7�ft. �IbsJR. �� in.to �llft. PROPERTY OWNER'S NAME/COMPANY NAME in.to __ft. IbsJft. _____ �in.t�"*�ft. �.li�t JCIi ppr�q in.to ft. IbsJft. _ in.to ft. �"� �� OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN _ � � �� Make �� From ft To ft. Type 111Cl�'�AIPR� f1tAP� __Diam. ___ SIoVGauze _�� Length�.#, �f Set between ft.and it. FITTINGS t! N STATIC WATER LEVEL " Measured from 62 tt(�Below �I Above land surface Date measured� � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �� ft.after L hrs.pumping 7V g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION t ,��,Pitless/adapter manufacturer i,�,j�•�4_a7[�T�.� Model �]Casing Protection j�](12 in.above grade [l At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted `�Yes �j No Grout materials f I Neat cement �entonite Concrete ❑Other_ From O To �ry ft. 3 ❑Yds ��(Bags HARDNESS OF From � To �3�+ h.naturetl f�.�b1�. �]Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO _ From To ft I._Yds ❑Bags NEAREST KNOWN SOURCE OF CONTAMINATION to fI bi8ck soft �0 2 / "" [[[,,, � / ...:s feet ��\ direction ---p� ��type \ a� Well disinfected upon compleJipn? � Yes I�;�No CZSy yC�lO�ii �LBJ 4 � PUMP C��/ r�� +� � t^� �Not installed Date instal� �/ � - �:� mC�2.1 iV Manufacturer's name � Y\ ! ( � Model Number HP 1�Volts �J r., 9tttK�� 9'iTE'� ��iIA ZQ� 1�� - .-- Length of drop pipe �..J..: ft. Capacity g.p.m. �t�� ♦�q �yn Type:�Submersible ❑LS.Turbine I�`l Reciprocating ❑Jet L� 1 t `f� qgqNDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes j o 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 sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. � �Tf St�fll R �+11 � Licensee Business Name L c.or Reg.No. fi r`'-� � �� L.!� Cer� d � pr entative �gnalure� � = Certified Rep.No. Date � Jim K.�hls LOCAL C�PY 7 6 5 516 Name of Driller IC 140-0020 HE-01205-11(Rev.3/07)