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'�~��. ' . F,(� ��b MINNESOTA UNIQUE WELL V�ELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTF�'(� '�� AND BOR/NG NO. CounryName WELL AND BORING �CORD�.q , ,,�} . � . . i � Minnesota Statutes,Chapterl��Y _, ��Jt` i.,7 �v'1-"r �: � � Township Na �e Township No. Range No. Section No. Fraction WELL/BORING DEPTH(complet2d);'�. DATE WORK COMPLETED 09 �kJ A14a'y,SW �� }4� �`�.�" 11-12�'ll1 G � DRILLING METHOD LOCATION: Latitude degrees minutes seconds " Longitude degrees minutes seconds ❑Cable Tool ❑Driven -- ❑Auger ��Rotary House Number,Street Name,Citg and ZIP Code of Well Location ❑Other l� �A� �tQ�tii ?t90t'�' �C� t�r0� 55391 DRILLING FWID WELL HYDROFRACTURED? �,.=�Yes ��, No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. ��t�,-�-�� From ft.To ft. a Showing property lines, ' N � � 9 �Domestic ❑Monitoring ❑Heating/Cooling .'� �;io s,buildin s,and direc�ion. USE _ __ _ � ,� J Noncommunity PWS _]Environ.Bore Hole ❑Industry/Commercial \ ��j �� ❑Community PWS _]Irrigation ❑Remedial ' -�-- --`- -' ❑Elevator ,]Dewatering ❑ � W ; ; ; ; E . �,/ � CASING MATERIAL Drive Shoe? ❑Yes Na HOLE DIAM. ..�: � '-- ---�-----'-- T �^' ..Y�+. �� f-,_,l Steel U Threaded U W�ed ,- - ' � � <% ,- -�---—._ '@ Miie �.i"�� ..... � Plastic ❑ 'i - 1 �� CASING � � � S � �� r Diameter Weight Specificatwns � . � � f—�Miie� �� in.To �� ft. Ibs./ft. � in.To ��ft ___ -- -— — ------ ��-�q PROPERTY OWNER'S NAME/COMPANY NAME _______in.To ft. Ibs./ft. " in.To�ft �',�.ke �,�al 1�� in.To ft. Ibs./ft. in.To ft Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE �.� Make Jfl}ijZ�Qj� From ft. To ft. ` Type �r�ecsr�2��5•��Diam. p ' �-�---�----_..._ r SIoVGauze Length I_f {, t.� s �f Set between ft.and ft. FITTINGS d STATIC WATE L Measured from � ft. Below ❑Above Iand surface Date measured � � � � WELL OWNER'S NAME/COMPANY NAME PUMPWG LEVEL(below land surface) �2rf ft.after � hrs.pumping r6�} g.p.m. Well/boring owner's mailing address if different than properry owner's address indicated above. WELLHEAD COMPLETION 5 i Pitless/adapter manufacturer x��t@W$tEC Model : '��Casing protection__....,_____ _____ �12 in.above grade I_�At-grade [�'Well House ��Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings.or other) � �ntanitp i� 50 3!J, Material `From To ft. Yds. �ags Matenal�atL1��To�ft ��I Yds. i�I Bags HARDNESS OF Matenal __._From To ft. ❑Yds. �,,'Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION e� cla� brawn soft Q i3 /!1 `' 4 _ j feet _direction � �type � �f Well disinfected upon completion? [�Yes ❑No �_.�..�-�. .'_=1_a:...��%.,� S�y CiB� ,)7C'IZQW 1��LlT"I 1 7 �z PUMP ua��'�7 (.'18� �ray 3�(�11�1 `l7 r+� L�Not installed Date installed ll,��lF — Manufacturer's name_ .��sC}laC�eC �_a. � �Q�t �+n �f¢ Model Number HP 1_Volts � 47ti ll Length of drop pipe__�� ft. Capacity __g.p.m �ii41�Cl.t�� ;r�y ��i�"� 5(} �j� Type:j�Submersible ❑LS.Turbine ]Reciprocating ❑Jet ❑ � ABANDONED WELLS cZay1 s�� [3y uICU1L�"� �� Ze�r poes property have any not in use and not sealed well(s)? ]Yes �No VARIANCE r.K'�R�� brflT*� �Qt� 1�U 1({(� Was a variance granted from the MDH for this well? [��.Yes No TN# WELL CONTFACTOR 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,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. �an Stodola tJell Dri�li s� uc�,. inc. 1591 Licensee Business Name Lic.or Reg.No. ,..:�' , �� ',l��` 11-1.�?-1.'t Certified�Representative Signature Certified Rep.No. Date � ' -; � :=: !' ; "�� tOr1o2� ---- _---- �. LOCAL COPY .• � .-- Name of Driller �: IC 740-0020 HE-01205-14�Rev.S/12)