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� � t �"b WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName � � WELL QND BORING RECORD ,, Minnesota Stafutes, Chapter 103I � � ��, �� Township Name Township No. Range No. :' Section No. Fraction WELL DEPTH(completed) Date Work Completed 7 �� 297 � 2-16-t� GPS ` DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds `i Cable Tool ��Driven '__�Dug ❑Auger [�''Rotary --.Jetted House Number,Street Name,Ciry,and Zip Code of Well Location or Fire Number � DRILLING FLUID WELL HYDROFRACTURED? !—J Yes �No Show exact location of well in section grid with"X". ketch map of well location. �. i e FROM ft.TO ft. Showing property lines, roads and buildin s USE � N 9 ❑Monitoring Heating/Cooling 'J ,� � � � , � �Domestic ❑Emiron.Bore Hole �Industry/Commercial i . .--- ' `- ---`-- �, j j ; ; S ❑Irrgation emedial / . �� Noncommunity PW i J R ' ; ; � � � � � ❑Community PWS ❑Dewatering '�; --'-----�-- --�-- ---'-- i / � CASING HOLE DIAM. w ; ; ; � e � '* Drive Shoe? ❑Yes �lo , � � . , T = -,s _ - :� � _;-----;----_�---_,-- / teel � h eaded � elded J� t ��T • ��W , , , , '/z Mile StiC / i CASING� la ❑ .ry --'--- --�------'-----'- 1 , DIAMETER WEIGHT �' � g � � �^� ' f .`� � . / _�I�in.to j$5 ft. Z.O� Ibg,/R �in.to�[. �1 Mile—� � � / . . in.to ft. _ Ibs./fl. �in.to_��t. �� PROPERTY OWNER'S NAME/COMPANY NAME r., in.to ft. IbsJft. in.to ft. SCREEN OPEN HOLE Properbj owner's mailing address if ifferent than well location address indicated above. Make a�� FROM ft. TO ft. �i2O .�[FVL�i1TK DC TYPe --�IiII1TITas–atT—Diam.� ►S`ri �BrR �s ��p+} SIoVGauze___•� Length� � � � Set between ft.and it. FITTINGS STATIC WATE L EL +. s }.' .J .� t�i.�_ r LI�+� �� ft.� elow , ��above land surface Date measured � �� � � PUMPING LEVEL(below land surface) t WEIL OWNER'S NAME/COMPANY NAME 1� fl.after �� hrs.pumping � g.p.m. `�- WELL HEAD COMPLETION :� � , v� Well owner's mailing address if differeN than property owners address indicated abeve. �Pitless adapter manutacturer._L��-�....��-�L>�__!--.�*x�l Casing Protection �4A�in.above grade ��a ❑At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATION Well grouted �Yes ❑No Grout material [�Neat cement ❑Bentonite �_1 Concrete,�iigh Solids Bentonite - from__�to�_k. �_ �.��yds. �ags from_�a to��__ft. ��.�� [�, c��-'bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. _,yds. ]bags MATERIAL NEAREST KNOWN SOURCE OF CONTAMINATION � e �+, .i- .. . f�� feet __ ��__ direction ', �ti�--�-.• -.� ]� .r– tupe .-� i � Well disinfected upon completion � es ❑Na �-„►... PUMP � ;Not installed Date installed ��l �� '"� - '.i`�' Manufacturer's name �lh.�.✓._,,,i�, �, �'•�'C`-�.. ;s � / . Model number � � HP_L[�,�Volts • ..��" � �� Length of drop pipe f�,,,/." ft. Capacity g.p.m. Type: ubmersible ❑LS.Turbine ❑Reciprocating ❑Jet ;] - . ABA ONED WELLS Does property have any not in use and not sealed well(s) ��,]Yes j�Jo VARIANCE Was a variance granted from the MDH for this well? �]Yes o TN# WELI 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. Licensee Business Name �� Lic.or Reg.No. _ ��/V `� o ed e r� t ve$ig� ure Date � -- Gtntck I�oce ; ' LOCAL COPY � '? � j � ^.� Name ofOriller �::_ J � J HE-01205-08(Rev.5/02) - IC 140-0020