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<br /> MINNESOTA UNIQUE WELL
<br /> WEL�OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO.
<br /> � CountyName WELL AND BQRING RECORD p'� ''"�
<br /> � ,'T,ip�,..�
<br /> Minnesota St�tutes,Chapter 1037 E �l�� .: JL` ,
<br /> Township Nam Township No. Range No. Section No. Fraction .�-WEI;L/80RING DEPTH(cpmpleted) DATE WORK COMPLETED �
<br /> �� �" '/, IfiC� n 6-2'S"06
<br /> GPS - ���RILCiNG METHOD
<br />' LOCATION: Latitude degrees minutes seconds �
<br /> Longitude degrees minutes seconds � . ��Cable Toof�� � �'Driven ��,Dug
<br /> I �Auger .�ofary Jetted
<br /> House Number,Sheet Name,City,and Zip Code of Well Location or Fire N�tber . � �
<br /> �� ��(� �,� � S�� DRILLiNG FLUID WELL HYDROFRACTURED? ,�.1 Yes '�^' o
<br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. -��� From ft.To ft.
<br /> N roads, uildin s,an direotion� USE _ Noncosmmund py�/g � �'�Monitoring ]Heating/Cooling �
<br /> �� Y
<br /> 9 �
<br /> _
<br /> __L____1_ __�__ ___:__ 'y �-]Environ.Bore Hole !�Industry/Commercial
<br /> �,�.7 • �� `Community PWS ;_�Irrigation �Remedial �i
<br /> --- �q � Elevator �Dewatering ] r��
<br /> w ' E y e. CAStNG MATERIAL Drive Shoe? � HOLE DIAM �
<br /> , ; , ; T
<br /> y �.J Yes �lo �r� -
<br /> �--- � � : '_` . �.,. :
<br />� V� ��Steel '�__]Threaded ❑Welded
<br /> , , , '/�Mile
<br /> , , . , , I � tastic �J
<br />,.: --,---—r----�-- ---:- 1
<br /> � CASING
<br /> S � Diameter Weight Specifications
<br /> F—�Miie—� �in.to���,.ft. 1+7 IbsJft. ��� _$_in.to__�.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to___ ft. Ibs./ft. �in.to�.
<br /> � �'�,�{e'(♦� n lR��4� _ . in.to _ ft. IbsJft. in.to.__ft.
<br /> s•.�s� aa�c a �7i lE: OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated above. SCREEN 2�t�.�.��
<br /> � � �y� Make From ft. To ft. ��`
<br /> aW�ra �LA�i'j 3
<br /> Type �{'� Diam.
<br /> � SlotlGauze "'� �yw� Length +
<br /> Set between � ft.and�ft. FITTINGS � ~
<br /> � � STATIC WATER LEVEL
<br /> /;� Measured irom q��,/�p
<br /> L7V ft.'�. elow i__;Above land surface Date measured �4��R
<br /> WELt OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br />� 1C7V ft.after is� hrs.pumping 9lJ g.p.m. �.g
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION � �(� '{-_-
<br /> �itless/adaptermanufacturer t.3--k���"�Al�del
<br /> F
<br />� � I,J Casing Protection m.above grade .
<br />� �'�.At-grade(Environmental Well and Boring ONLY) �
<br /> GROUTING INFORMATI N
<br /> Well grouted es n No
<br /> ,� Grout materials �..�Neat cement (_�entonite [.�Concrete 'j�'�,Other
<br /> From Q To f�t � _ Yds. ags
<br /> �s HARDNESS OF From � To_ .L��ft. �l���Bags
<br /> -GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
<br /> From�To�t. � ]Yds. ags
<br /> —*u NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> ---/ ���� �� �� �O feet � direction "»'+��.+C1 "�`�type
<br /> ����� � �� � ���PUIMPisinfected upon comple�ion? es ❑No �
<br /> �� � a ,
<br /> �` * � J Not installed Date installed �
<br /> ��'`W�`� � ��i ��� � Manufacturer's name
<br /> Model Number HP�Volts ���
<br /> Length of drop pipe ��.� ft. Capacity g.p.m.
<br /> Type: ubmersible ❑LS.Turbine ❑Reciprocating ' ��.Jet I '
<br /> ABAN ONED WELLS
<br /> . Does property have any not in use and not sealed well(s)? '���Yes '�, o
<br /> VARIANCE
<br /> � Was a variance granted from the MDH for this well? [_]Yes [ o 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 hue to the best of my knowledge.
<br /> Use a second sheet,il needed.
<br /> `� REMARKS,ELEVATION,SOURCE OF DATA,etc. �� ,,����,$ �IY �I�� ��� T�S� ��I
<br /> 1
<br /> E`
<br /> _ —_ ._____. — _ ,
<br /> Licensee Business Name Lic.or Reg.No.
<br /> -�..._�
<br /> ,..�,Gt+' .�_ � �,_ -�"��,�,
<br /> Ce d presentative Signature-' Certified Rep.No. Date
<br /> LOCAL COPY �5 0 6 �1 Name of Driller � ��
<br /> IC 140-0020 HE-01205-11(Rev.3/07) i
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