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t - <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UN/c]UE WELL NO. <br /> coU�cyName WELL AND BORING RECORD <br /> � in Minnesota Statutes, Chapter 103I ���� � $ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> {�coc�a I17 23 I4 �, �, ,,, <br /> GPS Latitude degrees minutes seconds DRILLING METHOD � <br /> LOCATION: — �� Cable Tool ��Driven � ,Dug <br /> Longitude '� _ degrees minutes seconds = r <br /> � Auger �Rotary ;Jetted <br /> House Number.Street Name,�iry,and Zip Code of Well Location or Fire Number -� -� <br /> Zl�f� LR7CLii �� � ViOTIO 55391 DRILLING�FLUID WELL HYDROFRACTURED? ❑Yes �No d <br /> Show exact location of well in section grid with"X".� � Sketch map of we!I location. �j'�t'O(�„Ce FROM ft.TO ft. <br /> N '--��;.�'f? Sho oladsPand buYld ngs USE - <br /> ; 7� []Monitoring �Ji Heating/Cooling <br /> ' � � � � �,_ � �Domestic ❑Environ.Bore Hole i.j Industry/Commercial <br /> - �,d.4 ±� LI Noncommunity PWS ��Irrigation Lj Remedial <br /> ` I i i � '" ,�Community PWS r�Dewatering ❑ . <br /> / h CASING HOLE DIAM. <br /> � w e T � / Drive Shoe? '�es [�No <br /> Ii �.Steel �Threaded �, �Welded <br /> � , , , r" Mile - - — — <br /> �� � ! \� I�Plastic (��] ,� <br /> ----- ------ --�----.- 1 �r <br /> � I ; ; ; CASING DIAMETER WEIGHT <br /> E �(� t <br /> F—1 Mile� ��j„�� �� in.to f1d� ft. �+ ___ Ibs./ft. �y�-in.t � ft. <br /> • in.to ft. Ibs./ft. '�in.��ft. <br /> PROPEATY OWNER'S NAME/COMPANY NAME in.to ft. IbsJfc �7��.�n. <br /> S�OI�Od �S� �ld IalJ1,r SCREEN OPEN HOLE <br /> `� _._ <br /> Property owner's mailing address if different than well location address indicated above. Make J4MS� FROM �ft. TO ft. <br /> 7�V7 ev�y�.$�S B�� TYPe 8�$i�e.� �tl Diam._ <br /> ���]Q�f$� t�A1 55426 SIoUGauze ,����_. Length ��___�_�_ <br /> Set between_. ft.and it. FITTINGS � � <br /> STATIC WATER LEV L � � <br /> / 7_p_AL <br /> s-14{J5-II4b — �s n�below ,J above land surface Date measured �T�� <br /> PUMPING LEVEL(below land surface) <br /> �� WELL OVJNER'S NAME/CUMPANY NAME � +� A�^ �� <br /> ft.after G hrs.pumping G*� g.p.m. <br /> - WELL HEAD COMPLETION � ,{ � <br /> Well owner's mailing address if dif(erent than property owners address indicated above. ��PiUess adapter manufacturer ��. _ T•-»�-�,- � �..�el <br /> ���Casing Protection '�'12 in.above grade <br /> ' ��At-grade(Ernironmental Wells and Boring ONLY) <br /> GROUTING INFORMATION i� <br /> Well grouted �Yes �� �No <br /> Grout material '�Neat cement f�Bentonite ��;;Concrete�'1-1igh Solids Bentonite <br /> from +��/� to 'M-^� ft. � � I yds. �ags <br /> from .7V to �l ft. ���� �y�. !�bags <br /> GEOLOGICAL MATERIALS COLOR H MATERIALOF FROM TO from to }t. ❑yds. ���.bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> b��iil7 �j,11�t1 � �.� :.f� teet �.?�..� direction �.� r - � , �:t <br /> � Well disinfected upon completion es ❑No �..�.�,,,�.,,. '� �„..r,i,.�.._... <br /> �rt *O �� PUMP <br /> 1 1 ..� _. /'�/ }i,�. <br /> '�����Not installed Date installed t <br /> r8 �l`� 4 SA qM Manufacturer's name �� ��----> � !"�i � .�J� `��_ <br /> ; 1 3CRJ 6i/V � ^ <br /> " Model number HP ���✓�. Vclts ������-%�`��J <br /> b�l � ��,�t, '",�1�} Length of drop pipe ��� ft. Capacity g.p.m. <br /> Type:�. Submersible ❑LS.Turbine ❑Reciprocating ❑Jet j� <br /> ABANDONED WELLS <br /> Does properry have any not in use and not sealed well(s) ❑Yes o <br /> VARIANCE <br /> i: <br /> Was a variance granted from the MDH for this well? �_�Yes . o TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best oF my knowledge. <br /> Use a second sheet,i/needed � StocioLa Weli fl�ti.11ing ca, 1�s �71!i(. <br /> �. REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Licensee Business Name Lic.or Reg.No. <br /> /� 1,.:- �� <br /> o epr tative Sig ure Date <br /> Jim Kahls <br /> LOCAL COPY �] �� � � Q Name of Driller <br /> I � H601205-OB(Rev.5/02) <br /> �� IC 140-0020 <br />