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MINNESOTA UNIQUE WELL <br /> WELL/BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORD <br /> Fieanepin Minnesota Statutes,Chapter 103I 7 4 2 7 4 9 <br /> � Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> " Urono I1$A 23�i 32 ,� Ri�t ,� SE,� 180 n Octaber 16� 2t306 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes__ seconds__ _ _ <br /> 'Cable Tool �.�rD.�r.ivIen► VC� �.Dug <br /> Longitude__ degrees minutes seconds .-;Au er �pi�y�1 G �;.'Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number � , 9 �l�- <br /> 300 Stubbe B$� � �i QI0110 DRILLING FLUID W�L Y CTURED? L Yes No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well location. VSt2= \V,� From .To ft. <br /> Showing property lines, <br /> N roads,buildings, USE ZDomestic G Monitor(ji��qrr o '-Heating/Cooling <br /> � and direction. '. I Noncommunity PWS �`'�n�on,.aS�re Hole .. ;Industry/Commercial <br /> . I I Community PWS #Irrigation . .Remedial � <br /> V' ( i. �Elevator ❑Dewatering f:�� <br /> ' �' ' ' � � - CASWG MATEAIAL Drive Shoe? � �.Yes _- No HOLE DIAM. <br /> :.. W ' , ' � E T _ ��Welded <br /> : , ; , ; I . �.Steel ❑Threaded '� <br /> --�--- --'--- -�-- --`- � ;. <br /> ' ; ' ; ' /z Mile � ..�--� <br /> � �� � <br /> �last c S 4& <br /> ' -:--- - �-- -.-- ------ 1 ,,,,� , <br /> ,, �+�"""'^'�" CASING <br /> � � y,#j Diameter Weight Specifications O1 L ' <br /> i �--'1Mile-� i ,K.(� _ R 175 -- Vi `�0 � <br /> in.to ft. Ibs./ft. -tp-=�in.to�ft. <br /> � in.to ft. Ibs./ft. "� in.to ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME <br /> in,to ft. Ibs./ft. in.to ft. <br /> Hitkory FIne HQ�B� OPEN HOLE <br /> SCREEN <br /> Prqpq�ty{yvnexr's�a�liQg address if ditterent than well location address indicated above. Make_.`� eO From __ ft.To ft. <br /> ri7 .DC/ 81.7 �t� <br /> �OAg LSL.a� � .75.756 Type _ __ Diam.__. <br /> Slot/Gauze_ i18C t Length_ _ � <br />- Set between L 7.,r ft.and a ft. FITTINGS � � p�C �r <br /> � STATIC WATER LEVEL <br /> ,' 97__ft.�Below -.Above land surface Date measured 1�^1�'�0� <br /> �. � PUMPING LEVEL(below land surface) <br /> . WELUBORING OWNER'S NAME/COMPANY NAME <br /> � Aickory Fine HO�B _ft.after hrs.pumping �O_ g,p.m. <br /> ;; WELL HEAD COMPLETION p " <br /> } Well/boring owner's mailing address if different than property owner's address indicated above. ':_.pitless Adapter Manufacturer �8'BS Model � <br /> � �O� R15 i J Casing Protection__ � _1$12 in.above grade <br /> LOAg L8�@ i MN SS3Sv �.At-grade(Environmental Well and Boring ONLY) - <br /> GROUTING INFORMATION <br /> Well grouted? �Yes �-No <br /> Grout materials , 'Neat cem nt '�Bentoni .Concrete ' :Oth <br /> From_�_To �� ft. � ��Yds. �Bags <br /> From To ft. I]Yds. 17 Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To__ft. �_�Yds. I 1 Bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION�{�@r . 1'CC� SeiTet <br /> C�.ay �eZ�OFl � 2d _ _feet __ direction type <br /> Well disinfected upan completion? �Yes ��I No <br /> CI.By grA�T 'Z� (� PUMP � <br /> �4'� /5l��j�-'' — <br /> J Not installed Date installed � <br /> C18�1 �t gISV@'�. g18�1 Ve i�� Manufacturer's name_ 7 � r +�'�� V 11�� � ' <br /> J k <br /> nA Model Number HP � /�Volts <br /> Fj'raYe� flt sand gr83T 1uv �25 Lengthofdroppipe � � � R. Capacity ` `- ._ g.p.m. <br /> Type::��6ubmersible G'LS.Turbine r I Reciprocating f�I Jet r <br /> Cl.$y bt grflV@� red �25 ibs ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? '7 Yes pQNo <br /> granel � SSIld �$y I�S i�o VARIANCE <br /> Was a variance granted from the MDH for this well? . �.Yes �No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> � The intormation contained in this report is hue to the best of my knowledge. <br /> Use a second sheet,il needed. <br /> ��� REMARKS,ELEVATION,SOURCE OF DATA,etc. SC@VeIIB Drilling � B�ii�iro�ntal Svc �IZSS <br /> � - <br /> Licensee Business Name � Lic.or Reg.No. <br /> ),\ � <br /> ;� �;.:y .. -� r _ <br /> Authorized Representative Signature Date <br /> Randy Johnson <br /> — — . --- — <br /> 7 4 2 7 4 g Name o�Driller <br /> LOCAL COPY HE-01205-09(Rev.9/OS) f <br /> ic iao-oozo <br />