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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD <br /> Minnesota Statutes,chapter 103I <br /> Township Name Township No. Range No. Section No. Fraction(sm.—►lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> 1 ft. <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> ❑Auger ❑Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. - From ft.To ft. <br /> Showing property lines, <br /> roads,buildings,and direction. USE N CI Domestic ❑Monitoring ❑Heating/Cooling <br /> I I I <br /> J L ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> _ <br /> ' ❑Community PWS ❑Dewatering ❑Remedial <br /> ❑Elevator ❑ <br /> W E CASING MATERIAL Drive Shoe? ❑Yes [No HOLE DIAM. <br /> '---T---r T <br /> , ❑Steel ❑Threaded ❑Welded <br /> '/z Mile ❑Plastic ❑ <br /> 1I CASING <br /> 1 Diameter Weight Specifications <br /> S <br /> 1 Mile I •• in.To ft. lbs./ft. in.To' ft. <br /> 3 ,» <br /> in.To ft. lbs./ft. in.To' ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME <br /> in.To ft. lbs./ft. in.To ft. <br /> :�Y <br /> OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN y e s <br /> Make johnsOn From ft. To ft. <br /> Type stainless Diem. <br /> ' ', <br /> � Slot/Gauze ' �� Length _ <br /> Set between 148 h.and 158 ft. FITTINGS . 1 1 > , <br /> STATIC WATER LEVEL j ,6 0 ft. 0 Below ❑Above land surface <br /> Date measured 3 r/�2 3 r 2 3 Dry hole ❑Yes ❑Mo <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> g t, ft.after 2 hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> Ef Pitless/adapter manufacturer j i t e wa.t:e r Model <br /> ❑Casing protection ❑12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material C U t t i f g rom 148 To -,`. ft. ❑Yds. ❑Bags <br /> Material b e f t O n i r 50 To ft. ❑Yds. ❑Bags <br /> Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO One bag=94 lbs.cement <br /> MATERIAL Driven casing seal From To Bags or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Clay Brown ' Well is _ _feet _. direction from type <br /> Well disinfected upon completion? Er.Yes ❑No <br /> Clay/Sand Gray S 1 PUMP ) <br /> ❑Not installed Date installed 9/6 i 2 3 <br /> C?p Sand r .3 Shafer <br /> .''s r O C Manufacturer's name <br /> Fine Model Number HP I Y <br /> • Volts <br /> Silty Clay/Sand Gray s fi Length of drop pipe ft. Capacity g.p.m. <br /> t , s ,,,., Type:D&ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> Gravel i.x n r. ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes ❑ fo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes [S No 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 /> .7!-toctola Well T.rillin 17,7 <br /> Licensee Business Name Lic.or Reg.No. <br /> 77,7-..e.(‘,„,---„,--- 727,,,,..' -, .- '*--' - - , <br /> Cerfified'Representative Signature' Certified Rep.No. Date <br /> LOCAL COPY 8 6 9 4 2 8 Name of Driller <br />-52603 HE-01205-18(Rev.3/19) <br />