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" � � . � MINNESOTA UNIQUE WELL WELL/BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING N�. CountyName WELL AND BORING RECORD �7 3 915 8 � i� Minnesota Statutes,Chapter f031 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED oto�o i�� z3 �a �,, ,,, �,a z�a � �—Za-� GPS DRILLING METHOD LOCATION: Latitude degrees minutes__ seconds . _ _ ��. �.Cable Tool �Driven -_'��Dug Longitude__ degrees minutes seconds flAuger �otary _1Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � � - G10V 1'+a)LCit �IC LL QL�O 5539 DRILLING FLUID . �L HYDROFRACTUREq? ❑Yes f o � Show exact location of welUboring in section grid with"X." Ske h map of well location. ��er �F-r� i From ft..To ft. howing property lines, N �� roads,buildings, USE �_ omestic I]Monitoring f-'.Heating/Cooling `. � � � � �y and direction. C��Noncommunity PWS 1=�Environ.Bore Hole �.J Industry/Commercial � � -� ` >J� ❑Community PWS .'Irrigation �� Remedial � � ; � ; ; '�Elevator _=Dewatering I I. �' ' ' ' � � CASING MATERIAL Drive Shoe? '. I Yes _ No HOLE DIAM. ` W � � � E T � I hreaded ❑Welded `, --�--- --'--- -�-- --'-- } _ Steel T � � �lastic i I �� --�--- --�--- --�-- ---�-- Mile '/z � � CASING , S � � Diameter Weight Specifications �1 Mile—�{ / , �''�, 4 in.to� R. L_�V_�Ibs./ft. �_ �__in.to_�ft. /�✓:r��,,..�.�.-.�. . =ii_„ .._�.,. )._3.- . in.to. .._._--n' ---Ibs./ft. — �in.to��ft. ,� . PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. �bsJft. in.to ft. ------ �--___. . �� Q Q(� SCREEN OPEN HOLE Property owner's mailing add�ess if different than well location address indicated above. Make �� From ft To ft. > �`!V7 7t11 Ot S TYPe _ _...Sts►inless �t�--- Diam. _. • > � SIoUGauze�yy�._-- __- Leng�h �r 'F �...- _--- �. �plcins, P�T 55343 � ,� Set between R.and ft. FITTINGS STATIC WATER LEVEL`/ q _ �_ ft..�8elow ��. .Above land surface Date measured/`27� PUMPWG LEVEL(below land surfaqce) � L WEWBORING OWNER'S NAME/COMPANY NAME ��__ ft.after 4 hrs.pumping �fJ g.p.m. i ' W LL HEAD COMPLETION � �� #- -�}� Well/boring owner's mailing address if different than property owner's address indicated above. . itless Adapter Manufacturer LT3'4vJy.i-�.J�-�"�3..,,M/odel � �.Casing Protection ._^`12 in.above grade � .At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION�( Well grouted? /`\Yes f.�No �/ Grout materials _�__Neal cement X"t3entonite � �.Concrete '��. I Other From____0 To �__ft. � _'�:Yds. �Bags From�To?22 _ft.E1$�tlt f1� �Y�� . �Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. i'�.Yds. I I Bags MATERIAL NEAREST KNOWN SOURCE OF CONTAMINATION C7� L� �rt /�► ��-�� feet C-�' diredion_��~"�. ��--u.N-��-''1'�e ltl U L « Well disinfected upon completion? f�Yes I I No �� � 1 �C PUMP U i �.'��Not installed Date installed �� G •G� - C�8 Manufacturer's name `��'�'"� Model Number HP � Volts _v Length of drop pipe �Q� ft. Capacity g.p.m. - Type:� bmersible 'J LS.Turbine .-Reciprocating C Jet I 1 ABANDONED WELLS Does property have any not in use and not sealed well(s)? �Yes�No VARIANCE y Was a variance granted from the MDH for this well? � �Yes ��No TN# �� WELL CONTRACTOR CERTIFICATION p 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 . L� s� REMARKS,ELEVATION,SOURCE OF DATA,etc. � a7t�OZS Well Drillirtg Co�� IQCs �LJJI Licensee Business Name Lic.or Reg.No. �_,� _ '��- // o� ori d epresentative Signature Date � Chl2C�C. �C� } _ , -- — — — __ _—_— — s LOCAL COI'Y 7 3 915 8 Name of Driller ;`� HE-07205-09(Rev.9/05) �-- IC 140-0020 � _ �