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�' __ A � MINNESOTA UNIQUE WELL WELL/BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. Counry Name WELL AND BORING RECORD �7 4 3 4 4� � - i Minnesota Statutes,Chapter 103I Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED 17 23 09 �a ��a ��a 219 n 1-k-fl7 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ C I Cable Tool � 'Driven �.Dug _ Longitude degrees minutes seconds "��"IAu er g .�Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number — � Cti1 � � �COIIQ 5539 DRILLING FLUID WELL HYDROFRACTURED? G Yes �.. o Show exact location of well/boring in section grid with"X." / Sketch map of well location. �teC Showing property lines, From ft.To ft. N // roads,buildings, USE �_.Domestic �-I Monitoring �.-.:Heating/Cooling . and direction. ❑Noncommunity PWS .�.Environ.Bore Hole I.1 Industry/Commercial i ,f �� ,-Community PWS I.J Irrigation '. '.Remedial . '--- ' ` -`-- -� � f �� ❑Elevator r'Dewatering I.; � �� ' ' ' � CASING MATERIAL Drive Shoe? �. I Yes I I No HOLE DIAM. Y `� W ' � � � E� • eel hreaded Welded , �.� l_ISt ❑T , , , , , , , r --,--- --•--- --�----�— �'" �Plastic =_ ,� i i ; i Mtle ��.;�� C�ASING � yz " ------ ------ --•-- ---�- '' 1 --� iameter Weight Specitications , , S , , �� 4 212 ft 2 l/llbs./ft. a$t� 8 JV tt. �1 Mile� �.:y�... in.to • ___,._ in.to n _____in.to _ _ ft. Ibslft. �in.to��7 ft. :: PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibslft. in.to ft. �� 4 ROberts R@SidEtitial RemOCI@lit� TnC. - - oPeN Ho�e SCREEN_� Property owner's mailing address if different than well lo/c�a�tion address indicated above. Make `�U�Zl�t'� i � From fL To tt. t 2999 W Cty Rd 42s �� 1W TYPe �ta�ltl�$s $t�l Diam. L L 1 '' �${T�iZe'�t71� 5>� Slot/Gauze. __. .�e�� _____ _ Length_�t� f' '�i� i Set between_.�1 ft.and�1�____ft. FITTINGS�_jT STATIC�WAATER LEVEL _.._�+ __ (t.�Below I �,Above land surface Date measured__� '*�� __ PUMPING LEVEL(below land surface) WELUBORING OWNER'S NAME/COMPANY NAME ^� __�7 R.after 2 hrs.pumping, 25 g.p.m. - WELL HEAD COMPLETION �}� - � `�_�;_ � Well/boring owner's mailing address if different than property owner's address indicated above. j�pitless Adapter Manufacturer�„^�"�'�^^'�'�'"'l�fodel ..J Casing Protection __�12 in.above grade CIAt-grade(Environmental Well and Boring ONLY) - " GROUTING INFORMATION/ Well grouted? j4Yes i �.No - Grout materials Neat cement�Bentonite i Concrete ! I Other__ From � To �ft. � y u. �.Y�ds. �Bags From�___To�R �$El][$i y�� :�Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_ To ft. ! 'Yds. �. �:Bags MATERIAL NEAREST KNOWN SOURCE OF CONTAMINATION clsy gcay sc�ft 0 90 __ � -�•..s.�.-- ry� , 1� /' ;<..� '- feet �� diredion � Well disinfected upon completion? Yes L�L No ,-�,.(y,�� +�' � s�arui gray soft 90 135 PUMP '�. I Not installed Date installed /� !� �G � � (,"I��T �r�$5j .�Q�t �,J� 21Q Manufacturer'sname `�S'�Y I1 ��Model Number HP , `� Volts � �� lo �l� Length of drop pipe � ft. Capacity g.p.m. Type: ubmersible i-�LS.Turbine �:Reciprocating , I Jet L ABANDONED WELLS Does property have any not in use and not sealed well(s)? i �.Yes V'No VARIANCE Was a variance granted from Ihe MDH for this well? ._.Yes�No TN/1 WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minneso[a Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,il needed. tL. T �= REMARKS,ELEVATION,SOURCE OF DATA,eta uVn Stodola Well 13rilling Co��ll�. 169I n _ _ - _-- — - ; Licensee Business Name 1 Lic.or Reg.No. � � - �� 7 i epresentative Sign� re Date � Chuck Moore , — - - -- ° LOCAL COPY 7 4 3 4 41 Name of Driller HE-01205-09(Rev.9/OS) IC 140-0020