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MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING RECORD 792017 Minnesota Statutes,Chapter 1031 Towns Ip Township No. Range No. Section No. Fraction �j WELL/BORING DEPTH(completed) DATE WORK COMPLETED Latitude degrees minutes seconds DRILLING METHOD LOCATION: ❑Cable Tool XEI n Longitude degrees minutes seconds ❑AugOther Rotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑Other ft ore Mirth ore Dr OCOM 553" DRILLING FLUID WELL HYDROFRACTURED? [-]Yes o Show exact location of well/boring in secti d with'X:' Sketch map of well/boring location. bentonite From ft.To ft. Showing property lines, Nleads, i ings,and direction. USE Domestic F1Monitoring ❑Heating/Cooling ______ ____ _______ �+ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial l l �1 ❑Community PWS ❑Irrigation ❑Remedial a____ _;_;__ ❑Elevator ❑Dewatering ❑ _ w i E T CASING MATERIAL Drive Shoe? Yes ❑No HOLE DIAM. --T----1- ---:-- I ,,,l//////-��- teel Threaded ❑Welded h Mile Plastic lCASING S Diameter Weight Specifications �/� F —1 Mile ( in.To +�.7V ft. lbs./ft. in.To__% PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. QIn.To_ X330 Colson custom in.To ft. lbs./ft. 37 yin.To_ #E �+t1s SCREEN OPEN HOLE Prope=rty owner's mailing address if different than well location address indicated above. 216 Water 5t Make From ft. To ft. Type eiaior, MN 55331 Slot/Gauze0 �tl Le fticLength Ole 40 # At Set between ft.and ft. FITTINGS2R"# STATIC WATER LEVEL Measured from 84 tt. Below ❑Above land surface Date measured — 13 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ec�n 50 31" ft.after hrs.pumping _g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION 1't��t� ��yJ(Pitless/adapter manufacturer �j Model Casing protection X2 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material be t0ildt!From Tom ft. 4_— ❑Yds. [ags Material n&tU=l f jrjj_W To—_13()—ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. El Yds. Ll Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION ClaY s brown soft © 4 /. feet A-1 direction / �.,.L broom/ Well disinfected upon completion? Yes [I No clay/rocks varied medim q4 21 PUMP c ay yellow soft X21 34 ❑Not installed Date installed 10-2-13 clay/sand a medium -+4 57 Manufacturer's name granite boulder white/ � 57 �$ Model Number '` HP_1 Volts 730 gray c ay F1raymed58 112 Length of drop pipe 126 ft. Capacity 9-p.m sand/silt varied medium 112 171 Type: Submersible ❑L.S.Turbine E]Reciprocating F]Jet ❑ yells ABANDONED WELLS city/sand gray soft 171 316 Does property have any not in use and not sealed well(s)? ❑Yes No gravel white soft VARIANCE 1. tom_ eal low/varied 316 33, Was a variance granted from the MDH for this well? ❑Yes No TN# sandrock/shale tail/o WELL CONTRACTOR der my upTION p This well was drilled under m supervision and in accordance with Minnesota Rules,Chapter 4725. medium 331 13" The information contained in this report is true to the best of my knowledge. Use a seconcbim needed. REMARKS,ELEVATION.SOURCE OF DATA,etc. Dion Stodol a 1*t t Dr lli ft 0L'• Im. 1691 Licensee Business ame /.l a/lGiil'a'sa6y{7Lic.or Reg.No. Orr 10.31-13 f d Fl6i5resentative Sig ure Certified Rep.No. Date 792017 �" e LOCAL COPY Name of Driller IC 140-0020 HE-01205-13(Rev.11/10)