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.-�-yJ9sw'4�c T�..CM�"e° .. +7YS:J@�'nr.-_��... l�a{.+R�'.sY�IM."'Q,^X� _ , �.. ,� MINNESOTA UNIQUE WELL ` ELL-OFs BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING RECORD � �•�� 9 t Minnesota Statutes,Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED / - '/< �� .. GPS ' DRILLING METHOD Latitude degrees minutes � seconds LOCATION: � — Longitude degrees _ minutes�� _ seconds ❑CableTool .Driven �,Dug — �_Auger �'Rotary L]Jetted Houps�e Number,Street Name,City,and Zip Code of Well Location or Fire Number — (70F/ �CCt! tiL[3( !�L� vL�IIO J��L3�# DRILLING FL�U,IyD WELL HYDROFRACTURED? ❑Yes � No Show exact location of well/boring in sec�on grid with"X° Sketch ap of well/boring bcation. �}j`��e From ft.To ft. Showing property lines, N . �...�rr ds,buildings,and direction. USE �,Domestic �,_I Monitoring I.-]Heating/Cooling __1___ __;___ __�__ ___t_ � �` �]Noncommunity PWS '��Environ.Bore Hole , �j Industry/Commercial ��.-''�� y�" �'. ;Community PWS , i Irrigation � �Remedial --�--- --- --� � "��f �-`� �__J Elevator � .Dewatenng � � . � .' `N , 1 r r E� �'r,,,*� CASING MATERIAL �-i readed �Yes We�'N�o HOLE DIAM. � � Drive Shoe. I l�, ,� \ :' Steel , _Th � , , , 'h Miie , . --;--- --;---S--r-- ---�- � \ Damleter�Plastic Weight� � �. � � � Specifications �1 Mi�e---� � _I,F__in.to. _��ft �_,t�IbsJft. �in.to__�,Q. .� PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. _��in.to_z��. R(� iK�n'ie�� in.to ft. Ibs./ft. in.to ft. SCREEN_ OPEN HOLE Property owner's mailing address if different than well location address indicated above. --- �� . � Make__��,�� t From . �ft. To ft. Type '34Cil�t�`gs �� Diam. /� SIoUGauze •�%�� _ _Length__�Fi__'�'� Set between��_�ft.and ��r�tt. FITTINGS ��Y'7�i� STATIC WATER LEVEL Measured�from �� ft.'*- Below ',_�I Above land surface Date measured ��'��n..__ WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �� ft.after__�______hrs.pumping � g.p.m. Well/boring owner's mailing address if diflerent than property owner's address indicated above. WELLHEAD COMPLETION {�?.Pitless/adapter manufacturer_j' ___ Model � �Casing Protection �}�12 in.above grade �..�At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION e Well g�� I j No Q �� 4 y[ Grout�ma�te,[ial��t _��tonit�oncrete ❑Other . E rom o ft. ❑Yds. �, ;Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. 'J Yds. �. �Bags MATERIAL From To ft. --..Yds. � ',Bags NEAREST KNOWN SOURCE OF CONTAMINATION �� t ,•/—+ feet �/ direction `��'.__e_.'."—.. ......::�.J--...s3YC6 w.r.. Well disinfected upon completion? jjc]�Yes �, �No .a PUMP ' J Not installed Date installed �� ' Manufacturer's name Model Number HP 3�`t Volt�� �� Length of drop pipe �� ft. Capacity g.p.m. Type:[� ubmersible . �LS.Turbine ❑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 TNri 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,il needed. �1� �+ REMARKS,ELEVATION,SOURCE OF DATA,etc. �1�A1 JC�Od.S WQi� �`y�l�� Q�• IL1C. 2691 Licensee Business Name �•�' Lic.or Reg.No. ' 4-i5-1� p sentative Sigrrature Certified Rep.No. Date 7 � ��i 5 � ctn�c�c ��re LOCAL COPY � Name of Driller IC 140-0020 H60120512(Rev.1Z08)