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„ WELL LiCPTION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. ��,ntyName WELL AND BORING RECORD �- /y � �� Minnesota Statutes Chapter f03! °'j 9 �� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed fl. '�.rartc� 11 e �3 U7 ��. ��. ��. 2C�8' �-��i-y6 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Du 4h 15 FflL'Z�t Lake Ix^•Ilc1 S C)Z'ollc� .`�a64 g / / ❑ 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 N �Zt�1 t�G� � � � � l,u/�L�. -; -;- -;- -; USE ❑ Monitoring ❑ Heating/Cooling ' i i i i �7 Domestic ❑ Communit PWS -'- -�- -�- -'- ❑ Irrigation y ❑ Industry/Commercial i i i i � Noncommunity PWS ❑ Remedial w E T ❑ Test well i i i i ❑ Dewatering ❑ i i i -r �/zlM�a CASING Drive Shoe? ❑ Yes �No HO�E DIAM. _i i i i_ I ❑ Steel ❑ Threaded ❑ Welded ; - ,- -, - -, 1 � Plastic ❑ S �-1 Mile-� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME Ei n in.to �C>t: ft. �.g Ibs./ft. f J�% �.�_n. Kei i:.n Vk�ter�� & ls:�;�x�:�,t�� • ��.to n. ibs.in. {�/� Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. _�-i�{t�� �I[�.��,.(j Vl�CS� D�7�Ve SCREEN OPEN HOLE S�.e. 7� i�� Make ��n from ft.to ft. Fcien Pr.�3irie, �l. �J�'1'�J�� Type 5�2III�iS rJt2�1 Diam. ` SIoUGauze �(��/�� Lengih � � Set between tt.and ^.r�o ft. FITTINGS: �' � � � —�� STATIC WATER IEVEL � WELL OWNER'S NAME `=t% ft. C�below ❑ above land surface Date measured �- �-y6 PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping�� 11L� 9 P m WELL HEAD COMPLETION �Pitless adapter manufacturer �'tl'�'Q�,$ PT Model ❑ Casing Protection_ C�12 in.above grade ❑ At-grade(Environmental Wells and Borings ON�Y) GROUTING INFORMATION Well grouted?�7 Yes ❑ No HARDNESS OF Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete F}i h Solids eenronite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �C.,;9 G from �� to �t�ft. G•-� ❑ ydsXE7 bags from to ft. ❑ yds. ❑ bags (�� (t A ,��j; from to ft. ❑ yds. ❑ bags NEARE-ST-�KN,yOW-N SOURCE OF CONTA�A/T1ION ��•� �.�.d ..57_Z� �E' .rC :3 ��'E±t ��3; �L�a � feet L., /"a s%� direction � � type Well disinfected upon completion? ❑ Yes ❑ No � Cla � & G.r��1 B-r��,� i� 1�,�' i 95 t PUMP n ❑ Not installed Date installed ��-'"��"7�! W"c1�E.'Y Sc�IICi (�(:3�'JI"t,:X.l' S �3�;i L�s8t Manutacturer'sname1��T��CS� j�_��,3 Model number HP � Volts Length of drop pipe �� ft. Capacity �� g.p.m. PressuXreTankCapacity �2r� �-^IY'�� Type: L7 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes �4 No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes [�No WELL CONTRACTOR CERTIFICATION Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE��,�� The information contained in this report is true to the best of my knowledge. DC7N S`tODC)Lta iro�,,L DRI.I,LING CO., IItiIC. `L7172 F E g 2 p 1997 Licensee Busines�s Name , Lic.or Reg.No. ' _ �' 1 8-26-y6 $ C4!�C�F C�RCNO �Auth rized Hepr entative Signature Date cnuck r�_�e t�-;�6-Sf� � ��`,,, �� Name ol Driller Date LOCAL COPY "�� �� HE-01205-OS(Rev.1/95)