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.. � p: F WELL LOCATION � MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. � CountyName WELL AND BORING RECORD �� ' S $ � � Q � �E..'t111P.�31T2 Minnesota Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed .��j . �i�._ i � - - fl. . !�� . y. '/. '/. � , _ - � � House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD �_ - "j�+ {. y ,� - . �� : ❑ Cable Tool ❑ Driven ❑ Dug jiiC�t��"1 rlt�I G B�'1 Z� (JI'Clj2(_�� t�. _`��_ J/% ❑ Auger I$Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ Showing property lines, roads and buildings. DRILLING FLUID i�7 � N YVii�e(�S 1 I I I 1 I I I USE � Monitoring ❑ Heating/Cooling i i � � �Domestic ❑ Community PWS ❑ Indust /Commercial � i + i ❑ Irrigation ❑ Noncommunit PWS ry - w E T M � ❑ Test Well y ❑ Aemedial i � � i ❑ Dewatering ❑ -r -7- -r- -r ��/ i i i �� i �ZIM.10 `+�� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. _i i_ L_ _i I �i ❑ Steel ❑ Threaded ❑ Welded � � � � 1 E�?Plastic ❑ S �1 Mile� ,r;' c-'f. . ,s�� CASIN.G DIAMETER WEIGy�j PROPERTY OWNER'S NAME f' � C}�' �"�L'� � � �� = �n.co ft. Ibs./ft. � t DL uy ;;t r'e 1 t;s�a m.�o ft. Ibs./ft. �ihlto`�ft:= Property owner s mailing address if different than well location address indicated above. in.to ft. tbs./ft. in.to ft. SCREEN C;f.:y i n 1�c s� C�� OPEN HOLE Make from tt.to ft. 0 Type Diam. SIoUGauze �� Length ^ � �` Set belween �� ft.and ��.=�ft. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME f'�• ft. C�below ❑ above�and surface Date measured �-�{J-� / PUMPINGLEVEL(below land surface) Well owner s mailing address if different than property owner s address indicated above. Z �� ft. after � hrs.pumping [.L� g.p.m. WELLHEADCOMPLETION ��-� ,Gati,.yu��e� ;"�'�:'F� � Pitless adapter manufacturer Model ❑ Casing Protection � 12 in.above grade � ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? C�'es ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material O Neat cement R eentonite ❑ Concrete CfiHigh Solids Bentonite MATERIAL from i 7 to _�`,Ut. L ❑ yds. L�bags irom to fl. ❑ yds. ❑ bags �,-�.a y ��.t`;' v (.r '1 � � irom to ft. ❑ yds. ❑ bags NEARESS�WN SOURCE OF CO�Tqqq N�Q(J,,, � -T'�✓ "�-C � / �° - �1�� E, �� , x �.: � , feet � direction �y'� , : type �, Well disinfected upon completion? j�Yes ❑ No `�� �C1T1C!-.�.71.1.L '1'ci It �1 �j ' � ��1: PUMP ❑ Not installed Date installed f)—��U—y 7 Vy��1rc��'1 �rC'��1.�'! � '� �F�} 1� tulanufacturersname / i`: ., ��,, Model number �F' Volis ��% Length of drop pipe 1 U�'' ! ft. Capaciry �� g.p.m. ��iiY�.l `?'c:lli �-�'i � yJ L�.. �ressureTankCapacity g��;y ys_.��'T � Type: t9 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Dces property have any not in use and not sealed well(s)? ❑ Yes C�2{lo VARIANCE Was a variance granted from the MDH for this well? ❑ Yes �►Jo a WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. Dl:1V �`�'r�>L:�:T,�� ,'�.LL DI�tZLLI�iG C(t. , Tr�C`. L�censee BusinessName - Lic.or Reg.No. r, ._ � � � �c. _ . j' - /`� � ` " ' �--1 �—�3? _ .�>:s�' _. � Aufhonzed Repre5eM3tive Signature Date L`t-ecz la�iby �;_13...c��; Name o/Driller Date . �J � �'� �� �9 '' p �'� HE-01205-05(Rev.1/95) �