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� ' - ' RECEIVED WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUEWELL NO. County Name WELL AND BORING RECORD SEP �2�� g�7 z @flnep�n Minnesota Statutes Chapter 1031 � �� , a Township Name Township No. Range No. Seclion No. Fraction WELL DEPTH(completed) C� e�c��O rono I37 23 8 �, ,,, ,, 152 3-14-�3 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds ��Cable Tool riven �Dug , �Auger �Rotary _ _Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � �. 3b25 N Shore DC� OCOAO DRILLING FLUID WELL HYDROFRACTURED? I�I Yes No Shop exact location of well in section g'n�i with"X". /� Sketch map of ation. Wg t C r FROM ft.TO fl. �"1y��M Showi roperty lines, _ -- ---- N '-`�" , ads and buildings USE ]Monitoring ❑Heating/Cooling � � , � ��No co�mmunity PWS � ��Irrigation ��Industry/Commercial ` J �,__Community PWS [�)DewateriBgre Hole � � � I Remedial '� --'---"-�"'""'"`'- ---`-- ASWG OLE DIAM W - --- -- E� C Drive Shoe? ._��.Yes o H . ;- - -, � F � [ I teel �Threaded �d � : ; �1M��e �--,� P�ast�� — — : : : ..� , ------ ------ - �-- --.— --� CASING DIAMETER WEIGHT ; ; S ; � � �4� __��0_i_ � 15�. � in.to fL IbsJfl in.to �--i nn�ie—; . ___ in.to__.. ___ft. Ibs./ft, in.to ft. PFOPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. ack Welch SCREEN OPENHOLE Property owner's mailing address if different than well location address indicated above. Make��j,i1$D.�--_ FROM ft. TO ft. `' 1$430 Cty xd 4 TyPe—��t[2��.��_a*�Diam.�—A � t��Ou�y' � �S/ `� SIoUGauze__.��_ _ Length�... . .. t� 1 k t `f Y Set between ft.and it FITTWGS STATIC WATE L ___3�____ft.,�below above land surface Date measured____��,_4}��— _ PUMPING LEVEL(below land surface) �� � WELL OWNER'S NAME/COMPANY NAME . . x --l�- �--- - hrs.pumping—�}Q_ ft.after__ ___ g.p.m. WELL HEAD COMPLETION Well owner's mailing address if different than property owners address indicated above. , pltless adapter manutacturer_ �t�te� Model ___ _.._ �- ❑Casing Protection_ ___________ " _�12 in.above grade 4 ❑At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATIO� Well grouted Yes ❑No Grout material �-��Neat cement �_,Bentonite i .��Concrete�High Solids Bentonite ; from_. _.Sl_to__�oat. �_y-- - �.--�.Yds. �bags �� from_�Q.to 152rt Qg.t.U,t$I, � ��.J,I�;bags . GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from___. to ft. _ _yda �__]bags MATERIA� `" NEAREST KNOWN SOURCE OF CONTAMINATION , ) - ' . ��._.J feet ��--"D._.Uirection ' . ��-.. �u--_tYP �.:� a soil lack soft Q 4 _, Well disinfected upon completion Yes No and ra soft � 12 PUMP -- � '�.Not installed Date installed ��—U'3 `� �� +8 aof t j 2 �,5 Manufacturer's name Asw..w�w.. Model number__ .__ __.HP�Volts_Z3Q. _. ___ and Ea �of r Z 5 1{Q Length of drop pipe _____��___ ft. Capaciry_ _____________g.p.m. Type: Submersible '��''�..LS.Turbine [j Reciprocating [J Jet I._�_. .� � � �A CH ��,{.�j�'� I}Q �I� ABANDONEDWELLS � � Does property have any not in use and not sealed well(s) ��Yes No and cs of t 115 1 S 2 VARIANCE � Was a variance granted from the MDH for this well? Yes '�, �No TN#_��,� WELL CONTRACTOR 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. DQn �_a��1�_��1 1. .n..3 1 1 /��. _T�C._�� f tuu�l �l 112.-s-i-i u _4 L Licensee Businesa Name ic.or Reg.No. i _. , ; ' 7-24-(33 , -:� :_� -- =--- ' ---- ----- u nzed Representative Sign�ture Date Chuck Mooce 7t-14-03 ___ -- _-- - � � �� Name ol Driller Date LOCAL COPY He-oizas-oe�Ra�-sroz� IC 140-0020