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; .. ......: ... ... .. . ...._. . �.., _. . _. .�, _ ,, . -+. ,. ., .. . _.__ . , , �_ ;. . _: . _. �. ._. _ ._ . _ , MINNESOTA UNIQUE WELL WELL OF�RIN��OCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name ' WELL AND BORING CONSTRUCTION RECORD ��l��n Minnesota Statutes,Chapter 10.?I 8 2 6 6 4� Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED th�ono 117 ?3 15 ,�S�a ��? �� 3 tt. �;_29-17 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven � []Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location []Other 2f�9� Shoreline DL�� COI7O 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o - Show exact location of welllboring in section grid with"X:' Sk ap o(well/bori g location. !')F,?(j��("1'2,t� From ft.To ft. .; Showing pr erty lines, ' �ads,buildings,a direction. USE N �Domestic ❑Monitoring [�Heating/Cooling .�', __ ___ _____ ____ ___ __ �� Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial �\ � ❑Community PWS ❑Irrigation ❑Remedial i _� � ❑Elevator ❑Dewatering ❑ � - `/� , , , , E T - ASIN HOLE DIAM. � � � � � ;. �' --�-----�--- --�----%-- I ' ��tl G�SteelAL �Threaded ❑Y❑We�do 'h Mile ) � ��'� C � ? ; ; ; ; StiC � � Pla --;-----�--- --�----�- , � CASING g � _��'p '�w,� Diameter Weight Specifications �—iMiie—� � 4 in.To c7l ft. Ibs./ft. in.To ft. �� PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. � in.To�ft. `�artha ?�eac2 in.To ft. Ibs./ft. in.To ft. � Property owner's mailing address if ditterent than well location address indicated above. SCREEN ?r. ,�,,� OPEN HOLE s�� Make From ft. To ft. Type Diam. SIoVGauze �' Length '� * Set between ft.and ft. FITTINGS ZpI�3� ��$�� STATIC WATER LEVEL �1 Measured from o� 4 h ft. Below ❑Above land surface Date measured C7'—� WELL OWNER'S NAME/COMPANY NAME pUMPING LEVEL(below land surface) A� c ' ft.after � hrs.pumping )� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adaptermanufacturer T�hitewater Model Casing protection �2 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material�i]tin[1�CP From_�To�_ft. __"� ❑Yds. '�Bags Matenal�.��C From_r To_��_ft. �Yds. ❑Bags Tr— HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION p ;. 7 7 7,, t ::-' '� „ ,': CJ.1.iy��Y'c'1VP_L VCf3Wn 11f�j.1:Ri1 � 12 `I�• feet '�-� direction r:'.� , �,.>.' �.."_ ��type ; �.: r �1 Well disinfected upon completion? Yes ❑No _ ��.��.—i_�L..�.1� $a�� hrc��ar $�lt �2 :l5 PUMP �Not installed Date installed ��iT1� Manufacturer's name S�`��L�C Model Number HP � �� Volts ��`'� Length of drop pipe �2 ft. Capacity g.p.m Type:�� Submersible J l.S.Turbine [�Reciprocating [J Jet ❑ ABA ONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes o VARIANCE Was a variance granted from the MDH for this well? �Yes No 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,eta } 1)on Stodola t�1e�1 nrillinU t�o. Inc. lh9i Af�{� J: ZJ �IJ i� Licensee Business Name Lic.or Reg.No. . � _ -. CITY 0�ORONO - 2-7-1�3 Certified Representative Signature Certified Rep.No. Date � 2 5 6 4 5 ��h �t«�a�a LOCAL COPY Name of�ri��er --- ID#52603 HE-01205-15(Rev.B/13)