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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AEND BORIN'�G NO. ELL County Nam� WELL AND BORING RECORD 7 g 3 5 0 3 `�p�� Minnesota Statutes,Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMP�ETED 4cbno 117 23 0� N� �W��NW �� 291 n 3—t7-11 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ . Longitude degrees minutes seconds _�Cable Tool � �Driven � '��Dug �i Auger ',�'�totary Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �� 2J(7 L P1SL`e vL� 5535b DRILLING FLUID WEL�HYDROFRACTURED? I I Yes �'No Show exact location of well/boring in section rid with"X" Sketch map of welUboring location. '�^"'�""'�"'� From ft.To ft. Showing property lines, road�,buildingS, nd direction. USE N �, �� [�f Domestic Monitoring ❑Heating/Cooling � � � : i. ��R,��. ..._. -. ,,�\_P,,,,a„� _ __;__ ;___ __� __,_ � ' '� Noncommunity PWS ��Environ.Bore Hole [ ]Industry/Commercial Community PWS �]Irrigation � !Remedial --- ----- ----- --- - �"�� \ � 1 .J Elevator ;_'Dewatering _., _ J _ I : : . \ - w ; ; ; ; e � '\„�_j� CASING MATERIAL Drive Shoe? U Yes �No HOLE DIAM. --,--- --�----�-- ---�-- T -�� ;Steel i�Threaded � J Welded , , � , '/Mile SIiC � ";___r____�__ � 1 ��. '�Pla �,�(�% CASING S � .. ,,y Diameter Weight Specitications �_�M�,ie� _�___in.to.___�.�fl �Ibs./ft. _.. �__in.to�' t. PROPERTY OWNER'S NAME/COMPANY NA E .in.to _.__ft. Ibs./tt. __ �in.to_��ft. s�� in.to ft. IbsJft. in.to____ ft. �� 'L� OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN_ Make _�� _ From ft. To._._,..... . ft. � Type��_=�'��8 � Diam. - — -- _ _�—� +� SIoUGauze •�� g � � . ----------Len th _.- - Set between__�,��__ft.and__Z�I iL FITTINGS_2��~ STATIC WATER LEVEL � Measured from _.��___ ft.,�Below ❑Above land surface Date measured__�j,7+■�� . WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �� ft.after_�_ hrs.pumping__�_. _g.p.m. � Weltlboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ,,y� �PiUess/adapter manufacturer�yiyt�=�r Model___ _ �Casing Protection ._ _._ _.___._ ��12 in.above grade �� (�At-grade(Environmental Well and Boring ONLY) GROUTING WFORMATION Well�� . �No �� Grout�n„�t@r 11�,�,f Ney�t�qrn�nt�enlonite�,qConcrete [�Other �, T�3CUC8S1 T 11 a 1t�4 From_ To. ft [�Yds. ❑Bags HARDNESS OF From_ To ___ft. �,-;Yds �—�.gags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �� - From To ft. ❑Yds. U Bags NEAREST KNOWN SOURCE OF CONTAMINATION ,��,..� �(/f __.-� . �� Z �� 0 J�.J�..✓ feet !`� _direction� �''"-'l� Well disinfected upon completion? 7{'Yes � �No ^-- C�S � �� PUMP .. - Not installed Date installed ��S'�l� � f�� `� Manufacturer's name �fer Model Number HP �!� Volts 4.7V �� Length ot drop pipe�'�� ft. Capacity g.p.m. Type�Submersible � ��LS.Turbine � �Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ^��.Yes.�;No VARIANCE Was a variance granted irom the MDH for this well? �_�Yes..�f 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. �bn Stodols WeII �Xillfc�g Co., Inc. �69I Licensee Business Name Lic.or Reg.No. � � .f,. 8—It}-lI e ed F(epresentative SignatJre Certified Rep.No. Date Ji� IGohl.a !! LOCAL COPY 7 8 3� � 3 Name ot Driller IC 140-0020 H601205-12(Rev.72/08)