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� 1 WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. ' CountyName WELL AND BORING RECORD �- - HPJ1T2Ej�lI2 Minnesota Statutes Chapter 103I J � 6 4 5 3 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed �.�'(.-"'IiC> �� c�_i �1 St` �.,�,�(;�,i. ��S' n �—��3—y�i � � r House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD r1�L3 �C3��tL51X�3.'e' �1VE-'`� �'[�Ik:3� �l. Jt..�.5�`J�; ❑ CableTool O Driven ❑ Dug ❑ Auger Q�Rotary ❑ Jetled Show exact location of well in section grid with'X". Sketch map of well location. ❑ .� - Showing property lines, .. roads and buildings. DRILLING FLUID N .FS2Z1�QF11.j�C' � � � � � -,- -;- -;- -; USE ❑ Monitoring ❑ Heating/Cooling � � � i �Domestic ❑ Communi PWS _i_ _a_ _�_ _i_ -------- ❑ Irrigation � ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial y� I I I I E . ❑ Test Well ❑ Dewatering ❑ i i i i ,�'M e CASING Drive Shce? ❑ Ves �Q90 HOLE DIAM. _� i _L_ _i_ � � ;, ��t ❑ Steel ❑ Threaded ❑ Welded I I I I Q�Plastic ❑ S �-1 Miie—� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME �:+' � ��' i•fA �' ��-' i]s`12L7G��:iI1C1 ��.C3�Y�:i in.to ft. Ibs./tt. in.;o tt. in.to ft. Ibs./tt. �'-j�,�o_�^�. Property owners mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. �t'J-�f� �1��3-� �� SCREEN_��_ OPEN HOLE 8��:�CdTll.72fy'�.C?21��1.�.`✓�{f7 Make from ft.to ft. Type `'�'¢ �� Diam. "n SIoVGauze �� V � Length � Set between �� ft.and t ' tt. FITTINGS: '� ^{ �� STATIC WATER LEVEL WELL OWNER'S NAME �i'fs' ft. C�below ❑ above land surface Date measured 7—�f5—��j PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. tt. atter hrs.pumping ?i��Y g.p.m. WELI HEAD COMPLETION �11�E��1,t�,�„�Z, C�{Pitless adapter manufacturer Model ❑ Casing Protection C�12 in.above grade ❑ At-grade(Environmental Welis and Borings ONLY) & GROUTING tNFORMATION Well grouted? C�`Ves ❑ No GEOLOGICAL'MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement C�Bentonite ❑ Concrete ❑ High Solids eentonite MATERIAL from i� to �ii ft. ❑ yds. q;bags '��E�.1C�y; �i..�� '�f�1�.C�1 H {� �cr, from to R. ❑ yds. ❑ bags from to ft. ❑ yds. ❑ bags � NEAREST KNOWN SOURCE OF CONTAMINATION (;]��T ('j�`-L�� ;j j j '�2�� feet direction type Well disinfected upon completion? ❑1�Ces ❑ No �71csVE:�. `��cill 1-� u.i S`� PUMP 1`-�J"��1 ❑ Not installed installed . �.��! Ure�, � C�"� 'c�y Manufacturersname �'��'E�` ��"' �-'"' rl:i_,st f,.'Ca � Model number HP -5,� Volts Length of drop pipe t ft. ,Cap,�ci g.p.m. Pressure Tank Capacity :�owrz�r.�;-";�:l.�,� `�=fir�- Type: C�aSubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Dces property have any not in use and not sealed well(s)? ❑ Yes C�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes O'Itlo WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. .k' REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my know�edge. � ��i;ix;LF? 4�3� DRILL�P+�G C.�;,, I1�C:.. Licensee Business Name - Lic.or Reg.No. 4/ �. �--'- � �{t'i-Q�T ��:�f�'�� Authonzed Representafive Signature Date �:Y�UC'}C MC'�(}L�f? /`^��i—�' �''' � �a , Name ol Dnller Date `...i�l.-l�� °-��[�'i` � � � ,�!. �r v ' HE-07205-05(Rev.1/95)