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�; , ..,_ _....� ..�. ._ �. ,. ,, _ , . ,.,,,... .. . � ..� _. w _, , . � ' MINNESOTA UNIQUE WELL WELL�OR BORI,LG LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. ' County Name WELL AND BORING CONSTRUCTION RECORD Q �} /� Minnesota Statutes,Chapier 103I '.J C--. �" � � Towns ip Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED ,� 1� " �1-�-�.�5 GPS LOCATION—decimal degrees to four decimal places). DRILLING METHOD Latitude �ongitude ❑Cable Tool [J Driven i�J Auger �;Rotary House Number,Sireet Name,City,and ZIP Code of Well Location ;�Other 1VSO L'il`�CWF)(�J �111� Rd� SliOTtO ��37I DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section grid with"X" Sketch map of well/borin o ion. ��e�. From ft.To ft. Showing prop ty es, ° roads,building and ir ion. USE �` rv � �Domestic �Heating/Cooling ^ __j___ __j_____�__ ___;_ A � ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ' ❑Community PWS ❑ iA2t�or�'� rt ;[]Remedial U ti -- - - C Elevator ❑�ewater�ig'`� ' ❑ . � .� . �' W ; ; ; ; E T ASIN MATERIAL Oe� HOLE DIAM. . ,_,� � C G , Drive Sh Yes No --�-- ' ' ---:-- � � � ❑ --;-- --�-- Steel ��'I�i�a�o� �. ; ; ; ; ��e � StiC '/M� �`� "�Pla � ��. --;--- --,-----�----.- 1 � ' � ' "� CASING S � �, Diameter Weight Specifications n; _ �i Miie—� ;� �',' �� in.To�,.7�__ft. Ibs./ft. _�__in.To_�ft. � PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs/ft. �in.To1�ft. f A in.To ft. Ibs./ft. in.To ft. St reetec C'[ tLg.�.�(.'• OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN 1g3I2 Mir�r�etonka Alvci Make ,JB�Ij�j1 From ft. To ft. �� 1SV�C1 �� S�3J1 TYPe-4�$•ttt�@�v-v�e��Dianf�p � � SIOVGauze ��in Length__�� }�� Set between ft.and ft. FITTINGS STATIC WATER ' � n�" Measured from 1t,K+ fl. Below ❑Above land surface Date measured j,�,�s��,�j WELL OWNER'S NAME/COMPANY NAME PUMPWG LEVEL(below land surface) � 1�5 ft.after 7 hrs.pumping � g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION F Pitless/adapter manufacturer � Model [�Casing protection �12 in.above grade ❑Ahgrade I I Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material }�nF��z.�.jtnFrom__9__To�_ft. _�_ jJYds. �Bags Matenal n�■t�z��From�__To__�_�_ft. �Yds. ❑Bags HARDNESS OF Matenal From To ft. ❑Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Dnvencasingseal From___To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION scI[A.! C.'i8 brc�m itsm (� 33 "��'� feet V� direction '�``` -'-'-'�e ' -- � .✓ ✓ Well disinfected upon completion? �Yes ❑No sasxi� c1a ra� fixn 33 91 PUMP [ ❑Not installed Date installed '� ��'AJCZa i'�r�� ) 91 lt.+ll Manufacturer'sname �C�l�r Model Number HP � Volts 230 L'�� 1�11) 1C� 156 Length of drop pipe �7 ft. Capacity g.p.m � �1$ Tr�.` ilHl) 1�6 ��5 Type:�Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS �Cl�/�kC$V�1 brown di� 1!5 1(�� Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE Was a variance granted from the MDH for this well? ❑Yes 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. - Don Stcx�o2a ��e1I �rilli.n�= Co,. Inc. 169I � Licensee Business Name Lic.or Reg.No. / � y �`�f' //:;��-� ��'17 Ce �ie&� resentative Signature�- � Certified Rep.No. Date Rab Str�dol� �ocA�coP,r 8 2 3 4 3 4 Name of Driller ` ID#52603 HE-01205-15(Rev.8/13)