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<br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIt�UEWELL NO.
<br /> co��cY rvame WELL AND BORING RECORD ('�
<br /> � �� Minnesota Statutes, Chapter 103I �1 �(� �.,i W���
<br />,. Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
<br />� GPSL�� 11Q `� � / / / DRILLING MET OD7 n 1Z�IS�J�F
<br /> Latitude degrees minutes seconds
<br />�;' LOCATION: — '_l Cable Tool i riven � .Dug
<br />�. Longitude degrees minutes seconds `�
<br /> Auger �Rotary I�Jetted
<br />� House Number,Street Name,City,and Zip Code of Well Location or Fire Number �J
<br /> fJY � t7 �CA�IO SS.7S� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No
<br /> Show exact location of well i�section grid with'X". Sketch �a f we!I location. �Ater
<br /> - Sh in roperty lines, FROM ft.TO ft.
<br /> ,�.� oa and buildings USE
<br /> � N i j ! `�` '� �Doncosmmuniry PWS 0 Monitoring ❑Heating/Cooling
<br /> � . _j____j_____�__ _____ En9ron.B9re Hole O Industry/Commercial
<br /> ,. j ; ' f ,_,N Irri ation Remedial
<br /> ., ; ; , , ! r,_ � ❑Community PWS ❑Dewatenn
<br /> --'-----'-----`-- ---�-- t ,�,(
<br /> , W i i i ; E \ \ ASIN Drive Shoe? ❑Yes �1 No OLE DIAM.
<br /> C H
<br /> _ __;_____�___ _.�_____;__ I A �� ❑Steel ❑Threaded ❑Welded
<br /> �( ,� k Plastic ❑
<br /> � � � � � Mile . ..
<br /> ,h .�
<br /> --------------------=- 1 ��
<br /> � � � � CASING DIAMETER WEIGHT
<br /> � � 5 � � 4�
<br /> � _�__in.to 191 ft. 2�lJl IbsJft �in.to�ft.
<br /> '�, �1 Mile--� �
<br /> q in.to fL _ Ibs./R �in.to��ft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft.
<br /> �1� M� SCREEN OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated above. Make� FROM tt. TO fl.
<br /> 15{7l � ? Type "�`����� *� Diam.
<br /> � ^t11
<br /> ���} y� 5��� SIoUGauze •V11J _ Length f + (�t
<br /> 1'!t� J Set between� ft.and_�ft. FITTINGS .��
<br /> STATIC WATER LEVEL
<br /> ��ft. �below C above land surface Date measured �,��f�
<br /> PUMPING LEVEL(below land surface)
<br /> WELL OWNER'S NAME/COMPANY NAME
<br /> __ft.after�____ hrs.pumping g.p.m.
<br /> W LL HEAD COMPLETION
<br />�?��i�. Well owner's mailing address if different than property owners address indicated above. �Pitless adapter manufacturer �it�.tec Model
<br /> � Casing Protection ._..____ I�12 in.above grade
<br /> � ' ',.J At-grade(Environmental Wells and Boring ONLY)
<br />, � GROUTING INFORMATION :�
<br />�� ,� Well grouted �Yes ['No b�
<br /> Grout material �, J Neat cement [J Bentonite . �Concrete�1 High Solids Bentonite
<br />�., from�to_�'ft �__ ❑yds. �ags
<br />. from�__to_��ft. ���!���❑bags
<br />- GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. jJ yds. �; I bags
<br /> MATERIAL
<br /> '• NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> V �'r� feet '' direction -�' y-_--�-''�T"tyFfe
<br /> ,�. Well disinfected upon completion es ❑No ._���•.+--.. �-'�-3-R.J��--e
<br />�� PUMP
<br />�^� ❑Not installed Date installed 1�'�Z�
<br /> Manufacturer's name �rn�tflr
<br />�':,�
<br />" Model number HP ��� Volts ��
<br />,'?:., —
<br /> Length of drop pipe ��/ ft. Capacity g.p.m.
<br /> � Type:. Submersible ', �LS.Turbine ❑Reciprocating ❑Jet j � '�
<br /> ABANDONED WELLS �-�
<br /> Does property have any not in use and not sealed well(s) L]Yes � No
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? ❑Yes 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,il needed
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. ]� ,S't,�(�,1�{ �cl� JJ�I1fT� C�- 3lx:s 4I1!-L
<br /> ,
<br /> Licensee Business Name �or Reg.No.
<br /> F :"���,� J,,..,-y,' ��
<br /> w - - 1-26-05
<br /> �� � ' . , .�r : ;;�=
<br /> �/1� A ho d`RepresentativeSignature Date
<br /> ~' -� _ti. ���L
<br /> :: / � 411i�t�lC �
<br /> � LOCAL COPY 7 ��Q �(� Nameo�Dril/er .
<br /> � � v � HE-01205-OB(Rev.5/02)
<br /> IC 140-0020
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