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� � . i WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD � �� -�- � �� n Minnesota Statutes Chapter f03/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed � 0 no I 1 2 3 b ��, �. �. ry 158 II-5-97 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 7gQ j� pj� �Z� QCpn�y � Cl Cable Tool ❑ Dyven ❑ Dug ❑ Auger L�Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ Showing property lines, � roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO " t�ater , , , , FROM n.to n. -; -;- -r- -,- j � USE ❑ Monitoring ❑ Heating/Cooling �omestic ❑ Communit PWS _I_ _J_ _�_ _I_ �E�� Y ❑ Industry/Commercial i i � i ❑ Irrigation ❑ Noncommunity PWS ❑ Remedial 'N E x ❑ Test well i � i i T ❑ Dewatering r7 -r -�- -r- -r i i i � �/2M.1e CASING Drive Shoe? ❑ Yes o HOIE DIAM. i i i i � ❑ Steel ❑ Threaded ❑ Welded -� - �- _� - -� l C�lastic ❑ S �-1 Mile-� �. m CASING IAMETER WEIGHT PROPERTY OWNER'S NAME � �4g g�r'�I 7 ��S 30 ; in.to ft. Ibs./ft. �in.to C Charles �illd� C� in.to ft. Ibs/ft. `�4in.to fL "�� Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./tt. in.to ft. i 802 Wooddale �r SCREEN OPEN HOLE i�oodbury, I�'!rT 55225 Make Johnsor� from h.�o h. Type_ Diam. SIoVGauze �A�1 A Length R � „M�_ .� Set between ft.and ft. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME 7� ft. �elow ❑ above land surface Date measured I1-5— 7 PUMPING LEVEL(below land surface) 1 C Well owner's mailing address if diNerent than property owner's address indicated above. 1�6 ft. after i�J _hrs.pumping �� g.p.m. WELL HEAD COMPLETION a��w�t e r C-�itless adapter manufacturer Model - ❑ Casing Protection �(12 in.above grade ❑ At-grade(Environmental Welis and Borings ONLY) GROUTING INFORMATION Well grouted? �Yes ❑ No HARDNESS OF Grout Material ❑ Neat cement C�`8entonite ❑ Concrete C3'9di h Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 9 from�to�ft. �� ❑ yds. ❑ bags C� v v /� from�_to t L Q R. �►��_��cf e�yds. ❑ bags SJ l��Qp '"4�� v �� from to ft. to�yds. � bags � NEARE6F1 h N'tliV,SOUACE OF CONT INATIO e I%� Clay/gravel. �rap �oft 3� 108 -� feet ,�i`,DtG�� direction rype Well disinfected upon completion? L�4Yes ❑ No � w 4- .� � Sand tan soft �i38 258 PUMP t n ❑ Not installed Date installed 2��`_�� Aer�otor Manufacturer's name Model number PN:�,/26Q� HP_��_ Volts Z�� Length of drop pipe �� ft. Capaciry g.p.m. � Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes C�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes C�lo WELL CONTRACTOR CERTIFICATION � Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. �� REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. _ _ -:.,., _ . ._.- Don Sto�ola Well Drillin� co. ,I�c. 7172 Licensee usiness N e Lic.or Reg.No. '.��'R 1 3 ��: ; :.---- _ , , ., � � .- . �; (,� y � ��Authorized Repr2sentati e Signature Date � __ ' r/�' ,¢'1��..,t,^!�_.i �� f �`f , . _ .^r- � / LOCAL COPY � C�C C �(� � NameofDril/er �: `T . f Date ''�U �.� U , � � HE-01205-06(Rev.9/96)