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MINNESOTA UN/QUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. ICountyName WELL AND BORING RECORD / ` Minnesota Statutes,Chapter 1037 [ � �J� � 3 Township Na e Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED ,, ,, ,, 228 tt 8-27-07 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds � Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug ❑Auger �'Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � 1377 North Arm Dr, VLV[R7 S�JVY DRIL�ING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. ��er From ft.To ft. Showing property lines, �' N �� -�-.__-�/T�s,buildings,and direction. USE l �No cosmmuni PWS -�Monitoring ❑Heating/Cooling 1 � � � � � _ � '� ty Environ.Bore Hole ❑Industry/Commercial � --'-- '------` --•- j;, j i i i !` ommu WS ion emedial i ❑C nity P J IrrigaT ❑R �� ❑Elevator ❑Dewatering ❑ , �'" , , , , E� ' 1 ASIN IAL OLE DIAM. C G MATER ve Shoe? ❑Yes �No H Dri � --,--- --�--- --�-- ---%— :. 1 � + ❑Steel �]Threaded ❑Welded < , , ; ; Mile Plastic '� � � � --.-- --,--- --.-----:-- 1 „ l y o V, CASING S � v� � Diameter Weight Specitications M p �1 Mile� ^ ^ � � in.to Z� ft. 1�9 Ibs./ft. �� 7 in.to �e� ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. IbsJft. `�4 in.t�`" ft. in.to ft. Ibs./ft. in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE Make 4 From ft. To ft. a4� a� 8� Type.4��1e.4� �t! Diam. _,_____ SIoUGauze �Q�,Q Length�� Set between ft.and ft. FITTINGS p « STATIC WATER LEVEL Measured from �,�-r��-/�� 65 g,�gelow j]Above land surface Date measured�J'�Gl—lJ/ — WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 2�" ft after ��+ hrs.pumping ��+ g.p.m. WelUboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ,.�, �Pitless/adapter manufacturer' .' � - �-� �� '��-•Model ❑Casing Pwtection �12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted �Yes ❑No Grout materials ❑Neat cement�Benronit�Concrete ❑Othe� From To�(��ft. p�Yds. �Bags � s ❑Bags HARDNESSOF From�To"'^' ft�t�81 j � . GEOLOGICAL MATERIALS COLOR FROM TO +��p �y MATERIAL From Gv� To`��1� [�'ds. Q'�ags NEAREST KNOWN SOURCE OF CONTAMINATION I / J `. `r?�_.J _feet l��l,[J direction �s...�>.r .. 11..�.}--.r�!YP ! � �� e Well disinfected upon completion? �,'�Yes ❑No -��t�-..,.��-��`""� PUMP .� ' I� �� /, '��_�Not installed Date installed '. l Manufacturer's name t �"�� Model Number HP ��Volts `��"�--'� � � � Length of drop pipe '.J`� ft. Capacity g.p.m. " Type: Submersible C 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 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. �_ �t�18 �t t �C,t 71�n�, �•' r�• I691 !. 1 L 111 �,�� —..—_._.-------- — ` Licensee Business Name Lic.or Reg.No. :- /�-�.i' G �t' rt'' d Representative Sigrfatu Certified Rep.No. Date LOCAL COPY � ��6 6 � -- �� — Name of Driller IC 140-0020 HE-07205-10(Rev.6/O6)