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` M/NNESOTA UNIQUE WELL
<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO.
<br /> CountyName WELL AND BORING RECORD ��� $ g 1
<br /> �tz�pin Minnesota Statutes,Chapter 103/
<br /> # Township Name Township No. Range No. Section No. Fraction WELUBORWG DEPTH(completed) DATE WORK COMPLETED
<br /> Ortmc� 11T 23 09 �F. N�T S�i,� f;j " c}i6..ZQ
<br /> � GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds _
<br /> Longitude degrees minutes seconds ��'�Cable Tool '�Driven �Dug
<br /> ❑Auger �Rotary ..;Jetted
<br /> House Number,Sheet Name,City,and Zip Code of Well Location or Fire Number ��,
<br /> 3115 Nor�h Stxi � T� DRILLING FLUID WELL HYDROFRACTURED? I I Yes �'No
<br /> Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. ��"�,rVliit� From ft.To_ ft.
<br /> . f Show' roperty lines, — -
<br /> / -� /roads,buil gs, d direction. USE �
<br /> :, N �./ y., ��,,�.__ -�j� . '�f Domestic J Monitoring ��_j Heating/Cooling
<br /> I I � ,_,�,L�.�;�.. '- �.�� �:
<br /> __,_ ___ __� _ ___._ ��� �-�Noncommunity PWS _��Environ.Bore Hole [l;Industry/Commercial
<br /> ��]Communiry PWS �. _Irrigation []Remedial
<br /> I I � ; �\y . . .
<br /> --'--- --i--- --F'----''- �..� ',
<br /> w ; ; ; ; e T �V CASING M I St elALr , �,Threaded 9�Yes �'No HOLE DIAM. "-
<br /> , , I Drive Shoe?
<br /> --�--- --'--- --F-- '
<br /> --- -- ' �,��,Welded �
<br /> , , , , /Mlle r,
<br /> , , , , � � , lastic R
<br /> --�-----T----�----:'
<br /> _
<br /> CASING
<br /> S � Diameter Weight Specifications
<br /> i � �R in.to�_ft. ��Ibs./ft. _�_��_�t.
<br /> t Mile
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft �in.to�',ft.
<br /> p� p in.to ft. Ibs./ft. in.to ft.
<br /> qCCC YO � OPEN HOLE
<br /> ��- Property owner's mailing address if different than well location address indicated above. SCREEN ____ �
<br /> 4 L,, --
<br /> :. �� Make �1QiH}�� -_- _._.__ From __._ft. To R �,
<br /> TYPe sg�inle�r� sti Diam.
<br /> Slot/Gauze_�oi� _ ___ Length_�_� .z t_�
<br /> ��—a f
<br /> Set between ft.and___ ft. FITTINGS_
<br /> STATIC WATER LEVEL
<br /> �� Measured(rom `��
<br /> ft. -Below ❑Above land surface Date measured �1 V*'�Q
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> �� ft.after ��J hrs.pumping �U g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
<br /> '�Pitless/adapter manufacturer �hit�ater Model
<br /> I Casing Protection �-12 in.above grade
<br /> I At-grade(Environmental Well and Boring ONLY)
<br /> GROUTI Gfy INFOR�MA�IO�N� No � �O �
<br /> Well�f� L �,
<br /> Gvo�YP�i,l�.g7 N�11c1r�ntltthBentonit�gConcrete [�Other
<br /> l.��L 2 1111 ,i�J LfJ
<br /> �* r'��To�ft. � ',��Yds. f�Bags
<br /> 1 ,y{,
<br /> HARDNESS OF j' From_ To R ��Yds. (J Bags
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
<br /> From To ft. �1��.Yds. �� '��Bags
<br /> L NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> '�wt u��� ��� � �v ��t`— __feet � ���-� direction �- � - ��rype
<br /> �f *p �/� Well disinfected upon completion? �.Yes 'J No -� - � �,-- �- �
<br /> '�� �y �OA� LCS *,7V PUMP
<br /> �� �r� J Not installed Date installed ���'i+LO
<br /> �s_ sOf t 6�T 70 , , ,
<br /> Manufacturer's name ,�-
<br /> ,
<br /> � �r� ��t �O Q� Model Number HP � Volts
<br /> C?"'"'� O �r
<br /> Length of drop pipe p� ft. Capacity g.p.m.
<br /> Type: Submersible ❑LS.Turbine ❑Reciprocating � �Jet .__ �.'
<br /> ABA ONED WELLS
<br /> Does property have any not in use and not sealed well(s)? �Yes � .No
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well7 - -Yes No TN#
<br /> WELL CONTRACTOR CERTIFICATION ��
<br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
<br /> The inbrmation contained in this report is true to the best of my knowledge.
<br /> Use a second sheet,il needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. � SC�OlA �eCI� �TC1111CI� �.cJ�• IE�G• 1 Vy�
<br /> Licensee Business Name Lic.or Reg.No.
<br /> / �-"'r-
<br /> -`��•/ �' t�"'�7��
<br /> -� epresentative Signature Certified Rep.No. Date
<br /> LOCAL CCJPY � � h� � �� C� �� —
<br /> Name of Driller
<br /> IC 140-0020
<br /> HE-01205-12(Rev.12/OB)
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