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<br /> MINNESOTA UNIQUE WELL
<br /> WIl�L/BORIT7l.',LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
<br /> CountyName WELL AND BORING RECORD
<br /> Bermepin Minnesota Statutes,Chapter 103I 7 4 3 41�
<br /> Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED
<br /> Occx�o i17 23 07 ,,. ,,. ,,a 1Q� n 9-22-�06
<br /> GPS DRILLING METHOD
<br /> Latitude degrees minutes seconds I Cable Tool i nven !Dug
<br /> LOCATION: ;
<br /> Longitude degrees___ minutes_ seconds [Auger ,�otary .!Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number L
<br /> 1tJl1S ■•■�� 1J�lIC� Or+o�o 55361i DRILLINGFLUID WELLHYDROFRACTURED? Yes No
<br /> � Show exact location of well/boring in section grid with"X." Sketch map of well location. NaL�r From $.To ft.
<br /> Showing property lines, -
<br /> N •� �s,buildings, USE _ omestic I !Monitoring '�_;Heating/Cooling
<br /> ��„�.,, �pd..dif�',tion. ��Noncommunity PWS I !Environ.Bore Hole '_'Industry/Commercial
<br /> � --'--- --'--- --`-- ---'-- '
<br /> C'Community PWS I..'��Irrigation �_'�Remedial
<br /> '�:Elevator I '�.Dewatering
<br /> ` ; ? ����� �-��"' ASIN ERIAL Drive Shoe? �...I Yes _ o HOLE DIAM.
<br /> �� C G MAT
<br /> W E T � � ��Steel I J Threaded I I Welded
<br /> � � �Plastic I
<br /> Vz Mile �
<br /> : --:--- --�-------- ---=-- 1
<br /> CASING
<br /> � , S , ,
<br /> Diameter Weight Specifications
<br /> �—1 Mile—� �_in.to.__l0i ft. �_�Ibs./ft. $$��! �_in.to,gL ft.
<br /> _ _ in.to______ ft. Ibs./ft. ____ _ �in.to�_R.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft.
<br /> Sto�ne+�aoci Design &iild �,C SCREEN OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated above. Make ��� From ft.To ft.
<br /> �' 7�FtJ7 ��t8 B�� Type _. .. �t���� $t� Diam._2� �'
<br /> T,.. L�T r` __—
<br /> i' S� LMji$ P$�� j�y,� �J'{2� Slot/Gauze __ . ___ _��,{� Length_ 1� ,} �
<br /> �Y-_.___._
<br /> Set between ft.and ft. FITTINGS „ R
<br /> STATIC WATER LEVEL
<br /> �� _____�}�___ ft.�Below '=��Above land surface Date measured__�(,(,�_.______
<br /> PUMPING LEVEL(below land surface)
<br /> WELUBORING OWNER'S NAME/COMPANY NAME A
<br /> 9� ft.after_ G hrs.pumping 35 g.p.m.
<br /> WELL HEAD COMPLETION �� yl�, }''� ���.�,.�,�,
<br /> ' Well/boring owner's mailing address if different than property owner's address indicated above. itless Adapter Manufacturer�,�-'"'•�`-''-"�'"''"- Model
<br /> . I Casing Protection �12 in.above grade
<br /> -��At-grade(Environmental Well and Boring ONLY)
<br /> GROUTING INFORMATION
<br /> Well grouted? �Yes I I No ,/
<br /> Grout materials '. Neat cemennt WBentonite I I Concrete 'Other
<br /> From_y_._ To_�.ft. __� ��Yds. -Bags
<br /> From�To��_ ft.������ �Bags _
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. s.
<br /> MATERIAL
<br /> - NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> r
<br /> i
<br /> �'�7 yellaw },f�� Q I C/� (eet � direction �'1" �pe
<br /> Well disinfected upon completion? '..Yes �--1 No <"�,,,�
<br /> � i� ��� �A PUMP
<br /> U t� (_ //,�
<br /> I 1 Not installed Date installed /� " `y 1`�+'
<br /> `►�p ��� �f� �$ Manufacturer's name
<br /> 1 f� ,�
<br /> Model Number HP�. Votts
<br /> � g�y �f t � 1� Length o(drop pipe �"� ft. Capacity .g.p.m.
<br /> Type: . ubmersible f]LS.Turbine -Reciprocating '..'�.Jet .���
<br /> ABANDONED WELLS
<br /> Does property have any not in use and not sealed well(s)? �.Yes j�No
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? �. '�.Yes ' .No TN/t
<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. �i�, *�� j �r
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. � SCW(J�$ 1�C�� �1��� ��� ZLIC• lU7I
<br /> � _._----- -.. .._. - __ _ •
<br /> Licensee Business Na e � Lic.or Reg.No.
<br /> f�- ;�C"�j O�
<br /> A z epresentative Si ature Date
<br /> �����
<br /> LOCAL COPY 7 4 3 410 Name of Driller
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<br /> HE-01205-09(Rev 9/05)
<br /> IC 140-0020
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