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�y . � <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> �� County Name WELL AND BORING RECORD _ <br /> �i� Minnesota Statutes,Chapter 103I � � � � � � <br /> - Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> � �COfIQ 117 Z� �i y �i y, ��g n �ZQ"�+� <br /> GPS � DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds l.i Cable Tool r;Driven ��Dug <br /> I i Auger �Rotary �]Jetted <br /> House Number,Street Name,Ciry,and Zip Code of Well Location or FRe Number �-� � <br /> P <br /> - + DRILLING FLUID WELL HYDROFRACTURED? �j Yes o <br /> Show exact locahon o well in section id iih'X". Sketch m�p of well location. W$ter FROM tt.TO ft. <br /> � � Showing properry lines, — <br /> - roads and buildings USE -- <br /> � N i ��Monitoring �;Heating/Cooling <br /> � I I 1 _ I j�Domestic [,Environ.Bore Hole �i �'�Industry/Commercial <br /> , --'-----'------`- <br /> �-��' [1 Noncommunity PWS �;Irrigation ;]Remedial <br /> ❑Community PWS ❑Dewatering ��li <br /> .. --'--- --�- ---- - �— <br /> ` - --'F - <br /> � <br /> � � , ��,,..// CASWG <br /> w , � � ; ET � Drive Shoe? �]Yes �:�No OLE DIAM. <br /> H ; <br /> ^ � ' �_ ' I ❑Steel ❑Threaded ❑Welded <br /> y --�--- --�-- --%-- � <br /> , � � � , I Mile --- <br /> ,� �� PlaStiC ❑ _ <br /> � ' -' ' � I 11 � CASING DIAMETER WEIGHT � <br /> � <br /> � S � L � <br /> , -T in.to �`"' ft. ��0� Ibs./ft. " in.to� ft. <br /> �-�M�ie-� ----- t <br /> in.to fL IbsJft. �in.toa�ft. <br /> -'� PROPERTY OWNER'S NAME/COMPANY NAME in.to__ k. Ibs./ft. in.to ft. <br /> �efl/utiL"S ffiebarth SCREEN OPENHOLE <br /> �+. Property owner's mailing address it different than well location address indicated above. Make_ ���� FROM ft. TO ft. <br /> Type �l'�8i1'i1�S14 S�__ Diam. �_ <br /> SIoUGauze �(�_,___Lengih ,�� * ��__ <br /> Set between__ ft.and it. FITTINGS M A <br /> STATIC WATER LEVEL <br /> 74 ft. below �_;above land surface Date measured ��� <br /> PUMPING LEVEL(below land surface) <br /> � WELL OWNER'S NAME/COMPANY NAME <br /> 17? ft.after 2 hrs.pumping 2� g.p.m. <br /> WELL HEAD COMPLETION (� �• � <br /> ~ Well owner's mailing address if different than property owners address indicated above. �pitless adapter manufacturer�_z.J-��f--.-���%��-e-.:��J�hel <br /> ��,J Casing Protection �j�y'f2 in.above grade <br /> �]At-grade(Environmental Wells and Boring ONLY) � <br /> GROUTING INFORMATION <br /> - Well grouted �Yes ❑No <br /> Grout material � �,Neat cement [;Bentoni't'�e(r����Concrete High Solids Benionite <br /> from_ 0 to t�"�ft. ��__ .?yd8.���bags <br /> from � to a�fL �t1��8� g�� I,I bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO irom to tt. � _yds. i`]bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ��p$�ll bl��lC $�iC V G -"—.�;..� feet J �J� direction ;,.,.1�.._' ... , :�pe��rl <br /> Well disinfected upon completion � Yes �No -�...% <br /> C�By bCOiil� AOIt L 1�? PUMP <br /> r / -� , �; � <br /> [j Not installed Date installed („� � 7..1 � <br /> (�+xgV p�V $�€= 15 �� Manufacturer's name -�---a:i� <br /> l d J 3 <br /> Model number HP'��Volts �✓ � <br /> � �t�� �t'$y �Ql t 1� 1 i0 Length of drop pipe /t�J� _ft. Capacity_ g.p.m. <br /> /�► C Type: - ubmersible !]L.S.Turbine [-�Reciprocating �_I Jet �I <br /> e�y grsy �f= ill! 1�J ABA ONEDWELLS <br /> Does property have any not in use and not sealed well(s) r;Yes nq No <br /> ; sand/�;tavel bt�m soft 175 I88 �AR�AN�E <br /> Was a variance granted from the MDH for this well? i_�Yes No TNIt <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 report is true to the best of my knowledge. <br /> Use a second sheet,if needed T�,..� <br /> ��;- REMARKS,ELEVATION,SOURCE OF DATA,etc. W/iStod.ola '�tel.IDtillicig Co,. 1�IC• �T112 .;; <br /> Licensee Business Name Lic.or Reg.No. <br /> `� / ' �it '�.? `��( <br /> Au z Re e"serita�e Signatu(e%� Date <br /> C�nu'� r'�'�tC <br /> LOCAL COPY ''' ^ �� NameofDriNer <br /> 7 � � � � � HE-01205-08(Rev.5/02) <br /> �� IC 140-0020 <br />