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WEI,L LOCA ON MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. . CountyName WELL AND BORING RECORD � g 0 5 7 3 �E-'�T��-'��1� Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) . Date Work Completed Urona 117 �� (34 4 tu� ` " 3-6-�7 ��. �. ��. House Number,Street Name,City,and Zi Code of Well Location or Fire Number DRILLING METHOD ,L f�'jr (.,ClL1Il�X"��3,.�2 �}11V� �GSt �2"OI1C��T'��. ❑ CableTool ❑ Driven ❑ Dug ❑ Auger �Rotary ❑ Jetted Show exact location of well in section grid with_°X". ��;� Sketch map of well location. ❑ Showing property lines, roads and buildings. DRILLING FLUID � f3'E.'1'19_:a".=Y? .. ' , � � � � -,- -;- -,-- -,- USE ❑ Monitoring ❑ Heating/Cooling � i i i Domestic ❑ Communi PWS � �Irrigation ty ❑ Industry/Commercial -�- -�- -�- -�- i i i i _ . ❑ Noncommunity PWS ❑ Remedial yy E '��" ❑ Test Well -�--� ' � � � i " y✓I ❑ Dewatering ❑ ` -r i i _r � �^��---.-.- '--" CASING Drive Shoe? ❑ Ves ❑)(p HOLE DIAM. '/zrnaa _� i _L_ _i_ I . � ❑ Steel O Threaded ❑Welded ' � ' � 1 C�Plastic ❑ S �IMlle-� � - !�- .-.-� j CASINGDIAMETER f. WEIGHT � , PROPERTY OWNER'S NAME �� in.to 1 �Jft. � ' � Ibs./ft. � in.io�t _�R rl`UI2y' �:1Ci@Tl E:t3�t�tc�It�7 in.to ft. Ibs./ft. in.to R. Property owner's mailing address if ditterent than well location address indicated above. in.to ft. Ibs./fl. in.to ft. ��I�1C� E!@Y�StZI.�'� L�TI� SCREEN OPENHOLE ��.�I[[�11't�l��I'1. �r�Q� Make a1 Ut121�(JTl from ft.to fl. TYPB �t�3.I�11.E�a G.i ��C.-'t��, Diam. SIoVGauze ]_(;s�i �e� length ' Set between �j�_ ft.and 1�< ft. FITTINGS: i� h. .'�.U tt fa'� ..t>. ��: STATIC WATER LEVEL � .: ¢ WELL OWNER'S NAME t�4' n. O�'below � above land surface Date measured �—b--�f � PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. ��F t` ` ft. after � hrs.pumping ��:"��l Ig.p.m. WELL HEAD COMPLETION h � � �- t�.,1 a�E.4�':t'�.�I C��Pitless adapter manufacturer Model ❑ Casing Protection �A 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete Q�iigh Solids Bentonite MATERIAL from �> to ��%ft. .% ❑ yds. � bags �C��.? �.'C�31.� �L:.ii�jS. 3 ;� ' � .r`, ; from to ft. ❑ yds. ❑ bags from to it. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION �1..��T BYGIWXl � � `." � !� � , feet direction �-rype Well disinfected upon completion? f3�Yes ❑ Na C..�c'1� CiT�� .rJ .f£� r i t f! PUMP ❑ Not installed Date installed --d � `�i�I1C��Clc"1�7 GZ'��l � � '�(' � � 'tj�nutacturer'sname n�'r;��u _�,� Model number �.��aGC v L�Y 7 HP ��'•'s Volts �.:�; Length of drop pipe_ � �� ft. apacity�`.�(�g.p.m. �'it:'.fi. ��'7illC'1. �L��.O�' G`� �u ��- { ��%�% lpressureTankCapacity �--'ti -'�f�'� Type: �.Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Dces property have any not in use and not sealed well(s)? ❑ Yes C};No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes dKNo WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was dril�ed under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best ot my knowledge. L�{>N ...•lt.7l3i,:�,i-i 44't.Ll� 1)R:i t.�I.T.�.0 :�i: � I�3�: Licen�pe Business/Vame Lic.or Reg.No. �e' f,/" - _��' � j � f L �', i .�? �ufhorized Representafive Signature' Date (:I�L2<"k I�'_•c?cY"e ._ -�--: ! Name ol Dnller Date ._ :� � �Pi � �, HE-01205-OS(Rev.1/95)