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�:��;:�.::�� � ,R � . .- , ,_. r .., . ,.. . - .... _ ._ _ , -:. ._. . . .. � - � . __ � . , MINNESOTA UNIQUE WELL ;: WELL�IR RORINa LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. v� County Name WELL AND BORING RECORD 7 8 8 2 4 8 �p� Minnesota Stat es,Chapter 103I Township Name Ownship No. Range No. Section No. Fraction WELUBORWG DEPTH(completed) DATE WORK COMPLETED �L'��'� - Z.1,7 23 �7 � �: �'�a n � GPS �, (� DRILLING METHOD LOCATION: �Latitude degrees minutes ___ seconds _____ Longitude degrees minutes seconds I�Cable Tool ❑Driven --- ❑Auger �(Rotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑p�her 15t�5 North Arm Dr, VL�F�Eb lSa[7�! ` DFILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X" Sketch map of well/boring lo ti �ter From ft.To ft. Showing propert e , N roads,buildings,and dir 1�. USE �Domestic ��Monitoring ❑Heating/Cooling " __J___ __�__ __1____`__ ]Noncommuniry PWS ❑Environ.Bore Hole ❑Industry/Commercial �Community PWS ❑Irrigation ❑Remedial � --i--- --'--- ---F-----t- j_�Elevator ❑Dewatering ❑ ��. W , , , ; E� CASING MATERIAL Drive Shoe? ❑Yes �No HOLE DIAM. 1 . --�--- -�-- , --�--- - --%-- - ._ ❑Steel ❑Threaded ❑Welded �� --�--- --�--' '--�-' --:" ile ��M 1 �Plastic ❑ ; ; ; ; CASING S ` Diameter Weight Specifications _lW � in.To �� ft. Ibs./ft. � in.To �ft �1 Mile� _____ ' J"• �� PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. IbsJfL �in.To��ft (�taclea/Jennifer Cogbill in.To ft. Ibs./ft. _ in.To ft SCREEN � OPEN HOLE Properry owner's mailing address if different than well location address indicated above. ��-- � Make From ___ft. To R. Type��_�t� Diam.__ SlovGauze � � �� Length�_______ Set between ft.and tt. FITTINGS A i } STATIC WATER LEVEL Measured from__ ft.�i Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) � 165 ft.after � hrs.pumping �v g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �„�f t��e� �]Pitless/adapter manufacturer��l� __ _ Model ' ❑Casing protection ,�12 in.above grade ❑AFgrade ❑Well House LJ Hand Pump GROUTING INFORMATION(specity bentonite,cemenbsand,neat-cement,concrete,cuttings,or other) Matenal ��Vtii��rom � To .7� ft. � ❑Yds. �Bags Material��E1t"$1 f�al�.— ,gl_To�ft. ❑Yds. ❑Bags HARDNESS OF Matenal_ _____From__ To ft. ❑Yds. �]Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION ��11� bi� $�ft 0 3 � �� feet �f1 direction �',. "X-_'` -`. ' ' ''"tyF�'e ��+ +� s} Well disinfected upon completion? �Yes ❑No C1A �� t�JCCLII�I} d `7 PUMP ttJCCLl Lj Not installed Date instailed /'.. � C�a �� "'" Manufacturer's name_ �� _ _ _ __ ��a �� Q Model Number HP�l�Volts_�_ Length of drop pipe 1G� ft. Capacity g.p.m � t8� �� *�p Type.f� Submersible I�LS.Turbine ❑Reciprocating ❑Jet ❑ a �' ABANDONED WELLS �1 �t.� ��s� 1 TD !85 Does property have any not in use and not sealed well(s)? ❑Yes No 33i7Fgx �.A �C.R.11 1/�7 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,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Dan Stoda►Ia We1I tk�illin� Co_,_._Iric. I691 i. Licensee Business Name Lic.or Reg.No. _ �t��/J �� -�-iz resentative Sig�r re Certified Rep.No. Date L_��:EaL ti;�r,.. 788248 � �t� Name of Driller IC 140-0020 HE-01205-13(Rev.11/10)