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, � _ � . � � � �. • ' ' MINNESOTA UNIQUE WELL WELL OR BORING LOCATION �" MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. ��. County Name WELL AND BORING RECORD 7 g 2�2 2 . ,.,�, F�erniepin Minnesota Statutes,Chapter f037 3 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED � (htmo l I7 23 Q7 ,� S't� 5�,,S Z28 n 7-8-14 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ Longitude degrees minutes seconds ❑Cable Tool [�Driven - - — — ❑Auger ,�'Rotary House Number,Streel Name,City,and ZIP Code of Well Location Fire Number ❑Other 43I5 I�cth Shote VC� VLViIV SSJVY DRILLING FLUID 'N/ELL HYDROFRACTURED? ❑Yes � No Show exact location of welUboring in sec id with" Sketch map of well/boring location. j��e� From ft.To ft. ._�,_� Showing property lines, .. .„,�/roads,buildings,and direction. USE � N �,.�� -___ �Domestic [�Monitoring ❑Heating/Cooling . ' ' ' ' _ � u ��•�-__�� []Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial � E/� / � � ❑Community PWS ❑Irrigation ❑Remedial . � ., I I I I , --�--- --;--- --�----a-- `_/ it ❑Elevator ❑Dewatering W ; , , ; E CASING MATERIAL Drive Shoe? ❑Yes .�No HOLE DIAM. --,--- --.--- --�----.-- T .� ; `�.� ��S[eel ❑Threaded ❑Welded :�. � ; ! � Mlle / BliC ❑ _ �� l �+ Pla �; --,--- --r-- --.----.- 1 CASING S � Diameter Weight Specifications �i nniie—� _�_in.To_�Q_ft. Ibs./ft. �in.To��ft PROPERTY OWNER'S NAME/COMPANY NAME in.To____,_ __ft. Ibs./ft. �in.To�f�ft M CJ' I t�UDt� zuJli7cs in.To ft. Ibs./ft. in.To ft Property owner's mailing address if different than well location address indicated above. �,�t,,�� SCREEN OPEN HO�E I�tM �t� eta„� 7+C,8�� Make JVi�I ____ From ft. To ft. i�XZBt� IN�I lS�1 e Type--J��-g�� —Diam._��_ - � SIoVGauze_� Length� _� Set between ft.and ft. FITTINGS STATIC WATER L � � Measured from / � L(��__ft�Below ,�Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ��V ft.after � __ hrs.pumping g.p.m. WelUboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer �f}Litet�tEr Model ❑Casing protection _ _ ____,_ _ �12 in.above grade � _ ❑At-grade ❑Well House � I Hand Pump � � GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) j�� Matenal-�y(I��fFrom__�To��ft. �' __ ❑Yds �Bags Matenal�a��a�€��To�ft. ❑Yds. ❑Bags HARDNESS OF Matenal___ _From To ft. ❑Yds. ]Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seai From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION c2sy/cockar e�i�� itl�ll�} � YG _ yJQ feet _ �.• direction `•_yJ`"-< >,a_s--K' � C*a� � �� A � Well disinfected upon completion? �].Yes ❑No �.�5�=�:a.�.-ci+ 1 L PUMP �/8 f�t r$� ��t LQ ��C ;_�Not installed Date installed 7�(� 1 �� Manufacturer's name �:�ll�cJ.�r Model Number HP �� Volts 2.71J sarxly clay ray medi�a 23S 2I2 p Length of drop pipe_ ft. Capacity _______ g.p.m C.�� .l�� ft�f ry+�►p Type: ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ 1D'L'Cil G.1G G4t7 D ABA DONED WELLS t Does property have any not in use and not sealed well(s)? (_�Yes � No VARIANCE Was a variance granted from the MDH for this well? ❑Yes '` o TN# WELL CONTRACTOR CERTIFICATION � This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. REMARKS.ELEVATION,SOURCE OF DATA,etc. Don Stodola �iell I)rilling Ca,. Inc. 1 I Licensee Business me Lic.or Reg.No. . �� , �r r ' d pre entative�i�ature Certified Rep.No. Date � 792022 � sr«�fl�$ � LOCAL COPY -- -_—__- -- _.—_ _ Name of Driller IC 140-0020 � HE-01205-13(Rev.11/10)