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,41; MINNESOTA UNIQUE WELL
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING Na
County Name WE L AND BORING CONSTRUCTION RECORD
��� '• Minnesota Statutes,Chapter 1031 821940
nship Name wnshipNo. Range No. Section No. Fraction '1 ` WELL/BORING DEPTH(completed) DATE WORK COMPLETED
Lona��o jig 013 3(l S 'I 'i 7 ea 4 n 94ok,
GPS LOCA ON—decimal degrees(to four decimal places). DRILLING METHOD
5/l� S9 5 g 0 Cable Tool Driven
Latitude on etude 93 3y y � ❑ ❑
❑Auger ❑Rotary
House Number,Street Name,City,and ZIP Code of Well Location Othe�hiey ' i-,.,
DRILLING(�acy 2 e.-6, &/a0/ 14AV' Oro c76
DRILLING FLUID y WELL HYDROFRACTURED? ❑Yes No
Show exact location of well?'oring in section grid with"X." Sketch map of well/boring location. idale,` From ft.To ft.
Showing property lines, 4�/
N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling
___ _ ___ ___ P �oa ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial
f4V tt ® x Community PWS ❑Irrigation ❑Remedial
❑Elevator ❑Dewatering ❑
/-1 CASV
w E Q r G MATERIAL Drive Shoe? X Yes ❑No HOLE DIAM.
--------I----y------L-- T : ,i00Steel ❑Threaded gWelded
Miie ❑Plastic ❑
-'-- ' ` f 1 1 CASING
s Diameter Weight Specifications
Q
� 2a7'c, ,/-id a z/ in.To 3-3/ tt.94/-/a lbs./ft. -._63-/.> a3 in.T ft
�--1 Mile--( Sin '
PROPERTY OWNER'S NAME/COMPANY NAME /Q in.To3lj/() ft.70.Sg lbs./ft./L5„3-/ /f in.Try,/�ft.
td
) 4 in.To ft. lbs./ft. in.To9� ft.
(�JSCREEN �DYIri 31/YI OPEN HOLE
Property o ner' ailing address if different than well location address indicated above.
Make „eal From ft. To ft.
7,5a/4Lc,YX-tel Type 1/_5/0T Diam. /�, TC/(
t&/� SIoVGauze ,30 ,5/OT Length /33n
OIW, m/1/ 56-35Z0 Set between 965/„ ft.and, 3/,as- ft. FITTINGS i4 dkGr
STATIC WATER LEVEL Measured from? r/yy..-4
RECEis(1 ftBelow❑Above land surface Date measured 9/ //,
47
WELL OWNER'S NAME/COMPANY NAME 'V .$Et PUMPING LEVEL(below land surface)
` CYMeJC}J'I1y' _ /�/ ft.after o.2 hrs.pumping i/30 g.p.m.
,:nroring owner's mailing address if different than property owner's address iinWed aL le2O17 WELLHEAD COMPLETION
/ ❑Pitless/adapter manufacturer Model
C'N ❑Casing protection P'fr1.above grade
O�ORONc�At-grade ❑Well House ❑Hand Pump 55/; �$
ROUT INFORMATION/ R1//JJ (specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
Material/(/1ahlO From 0 To..2_. / ft. /9 A Yds. ❑Bags
Material From To ft. ❑Yds. ❑Bags
HARDNESS OF Material From To ft. ❑Yds. ❑Bags
GEOLOGICAL MATERIALS COLOR FROM TO
MATERIAL Driven casing seal From Q To33/ /7_Bags
� //JJ NEAREST KNOWN SOURCE OF CONTAMINATION
Q,Q2 Ai/�'!L-F"c.ld 3/t - . . .• /490 feet A.4,-) directions type
Well disinfected upon completion? X Yes ❑No
PUMP
XNot installed Date installed
Manufacturer's name
Model Number HP Volts
Length of drop pipe ft. Capacity g.p.m.
Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑Yes X No
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes 1K 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,etc.
Nark / t //
� STriI�2QQ5/i t . /4/05
l' Li se Business Name Lic.or Reg.No.
C� ---/(4.--1....r_21/11
,_5-m9 A0 7_/cam
Certified Representative Signature Certified Rep.No. Date
IMPORTANT-FILE WITH PROPERTY PAPERS WELL OWNER COPY 821940- L9r/Cr/7 7 r7uf' 1r/6/6- &ra k"
Name of Driller
ID#52603 HE-01205-15(Rev.8/13)
r L, [,QUE# ''52-01-f°
Geological Materials I Color Hardness of From I To
Materials
' 5e,f gf K S C 2-
r
r l4 y y11Ue( All (7) Z 35—
I , vet vej Sri _ S 35- ‘7
GI ky y/?vci 4 Koc-r-S. Y ., N E 7 7 0
7rtitit/ d- 466/45 q/67Y 5 .70 7z
cf, )le/ 5 7Z- 96
S,('fri 9', Pi 9a 77-
C(4), 7'(y ,/1? 71 /
si i- 7/ ' s i zo (z3
qv - 7(• (-Y
/c�r .5 /Z3 /yd
u4,� s(/"! /hey 5 j//4 /yz
Ry ;4 It 1�� /14'
a 4✓ %6/L/ lick /1 l�Y 177
F,ir- Brod 4- Sr jt' fly I( 10 /70
city q 7f?4.e[ � � 07 170 /73
7(ivr/ 1'�' 5 /73 i 7 9
For 5.:94 F1). 6lN 5 /7? /5'1
?i,e(,e/ t/(I S _ /g/ l I?
tve 54 Ai ire 5 /6 /9
7/`1 soli g n- 5 _ /7/ 2/
F/le 5'9,)i 8IA S 2/6 Zl
44 i -+��,�e/ 6c/i/ ESC n�!zl/9 293
Fel ..C 5"/r`! J !i 3 L�o
S I/ix G/-wc/ S 2_ -.c:) 25'.sr
5, F'it Sqnd 5 2-47.5" Z4,
o(e4 4 ��,k e/ atilt /i 4,� p / r✓lr 5 2_.60 27e
re./.e 5 4 44d Glt-/h_ 5 070 , foo
Ir 4to/IG 4 ,1/4ve/ >tl/'w 4- int.IA' 3 3'c 3z(
f,ale T1-1/l2. Gf- Pe/70{,/ 5' Z-/
t ?ZS
rnCs 1t }-U-'/-m <e �d ari ✓_`, 1j i ZS~ 3S_S
_daffy & 4-(rihosr,11 w/ fes/ c.(,..,.,�, 55. fedc,,c,,, -,./7 5 34s 3�
5945 ,:6749/C,y w/igyaf,-1-cvio, Zco��� OPe.,4in i-i fiteen S(i/de� s 3�0
36s-
ef-rtd S5 rr,�t2- t GdLwn� /17 3e' ?'70
5'. , c�rf9 .11 ISm v'5 37o G A
5.5, Cf ,'i 3 yoo 'fS'
Sid 5t- $- S/-/e /C'i . c/ui 5 /AI s40/e, in/ 4 yS �/6Zr�
fiC,r1 5' r7-'k. 4- SA,9(Q. Glehm - yin5��7@, _/11-I q42-S— `7,`'g, C-