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UNIQUE <br /> WELL OR BORING LOCATION <br /> MINNESOTA DEPARTMENT OF HEALTH MIN ASSOTA ND BORING NO.WELL <br /> County Name WELL AND BORING RECORD 760625 <br /> Minnesota Statutes,Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> 7 23 07 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds E]Cable Tool El Driven Dug <br /> E]Auger ?Ootary E]Jetted <br /> House Number,Street Name,City,and Zip Coop of Well Location �or Fire Number ❑ <br /> 0. <br /> SW North Milwe ft. Qqm SQL DRILLING FLUID - E1: HYDROFRACTURED? ❑Yes o <br /> Show exact location of well/boring in section grid wit "X" •7Skkettcchh map of well/boring location. �,"` From, ft.To ft. <br /> She property lines, <br /> N 1I ro ,buil s,and directi SE [ omeslic ❑Monitoring ❑Heating/Cooling <br /> -----------------=-- ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> �� ❑Elevator ❑Dewatering ❑ <br /> w E T Shoev LWo HOLE, � CjASING MATERIAL Drive ❑Yes E DIAM <br /> -n steel ❑Threaded ❑Welde7"""" "." <br /> 'h Mile aslic ❑ <br /> CASING <br /> S Diameter Weight Specifications <br /> 11 <br /> 1 Mile 4 in.to ft. 1LAIbs./ft. a in.to 3011. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.toll"ft. <br /> n.to ft. lbs./ft. in.to ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN_ OPEN HOLE jojo� <br /> Make From ft. To ft. <br /> Type Diam. <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS <br /> + STATIC WATERML Measured from <br /> 53 ft. elow ❑Above land surface Date measured <br /> WEL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after 10hrs.pumping 25 g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �{� <br /> �itless/adapter manufacturer t.,t..l't. del <br /> Casing Protection (in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted [_-*s ❑No <br /> Grout materials ❑Neat cementntonite ❑Concrete ❑Other <br /> From To 30 ft. Yds. IFBags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From ��3t© To�ft. Wt — Ej Bags <br /> MATERIAL From W To 108ft. Yds?[Xags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION r'7 v <br /> J feet —direction -�'• a ti <br /> O� soft 3 9 Well disinfected upon completion? es ❑No NJ <br /> CbW PUMP <br /> . J soft _, _,40 El Not installed Date installed <br /> Manufacturer's name <br /> Model Number ../ HP J Volts 0 <br /> Length of drop pipe �` ft. Capacity g.p.m. <br /> Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes AO <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes Pgo TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. -. <br /> xw. ton <br /> Licensee Business Name Lic.or Reg.No. <br /> o <br /> Cer pr at Certified Rep.No. Date <br /> LOCAL COPY ---F760625 <br /> Name of Driller <br /> IC 140-0020 <br /> HE-01205-11(Rev.3/07) <br />