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? � MINNESOTA UNIQUE WELL
WELL DR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO.
�� County Name WELL AND BORING CONSTRUCTION RECORD �� � 4 4 2_ �
Minnesota Statutes,Chapter 103I —
� Town Township No. Range No. Section No. Fraction WELUBOAING DEPTH(completed) DATE WORK COMPLETED
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GPS LOCA ON—decimal degrees(to four decimal places). RILLING METH D
Latitude longitude ❑Cable Tool ❑Driven
❑Auger �Rotary
House Number,Street Name,City,and ZIP Code of Well Location ❑Other
1W B�$ sic�e Trl UCOTKI 5535b DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o
Show exact location of well/boring in section grid with"X:' et h map of well/boring location. �j')tonite r ft.To ft.
� Showing property lines,
N l� ads,buildings,and direction. USE r�(Domestic � oni onng �Heating/Cooling
� ______ ______ __?_____;__ � �Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ���
J Community PWS ��9�n� ���7 �Remedial
--- -- -- � ❑Elevator �Dewatering �'
W ; ' ' E �' ASIN RIAL � HOLE DIAM.
, , � C G MATE f rive Shoe.^ Yes o
� ------ --=--- --�-- --:- T � c o h� ��
I I I I '/
❑Steel �tlV
. � ; ; � z Mile � ' lastiC �` �
--,-----,-�- ---�-- --.- 1 �
CASING
S � Diameter Weight Specifications
�1 Mile� �in.To�ft. Ibs./ft. �in.To�ft. -
PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. Vil in.Toi�tl ft.
t'�St � x�� in.To ft. Ibs./tt. in.To ft.
Property owner's mailing address if different than well location address indicated above. t
SCREEN OPEN HOLE
1Q425 Bluff Rd Make J�n�� From ft. To ft.
Eden Prairie MN 55347 TYPe �'A{^le.as ster�l o�
� SIoUGauze �1 f1 Lengtt�f ,k )t
Set between ft.and ft. FITTINGS M
STATIC WATER L V L �
�} Measured from
7/ ft. elow �Above land surface Date measured � �`
WELL OWNER'S NAME/COMPANY NAME � PUMPING LEVEL(below land surface)
1'f� ft.atter G hrs.pumping 3V g.p.m.
Well/boring owner's mailing address if difterent than property owner's address indicated above. WELLHEAD COMPLETION .t
�itless/adapter manufacturer�1t�te� Model
❑Casing protection �'12 in.above grade
❑At-grade ❑Well House ❑Hand Pump -
GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
Material �l1�(3!'11 tP�om_�_To_��ft. _�_ ❑Yds. �Bags
Material [M1�}t��From_�__To 7 SG 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
�O 11 R118ClC sQ3.� Q 5 '"')'� ___feet _ direction - ---� type
Well disinfected upon completion7 �'Yes [No
cls bro�m med3u� 5 2C PUMP
❑Not installed Date installed ��G�"1 1
5�323C� L'1-8 l rtlVE' 'La t1���11flI 2�3 �7 Manufacturer's name
���"�/ Model Number HP �y S Volts I
ratvel/sarxl 111�.X L`OLICS£ 8? ���' Len th of dro i e 1n C ft. Ca acit m
f� .X 9 P P P L1J.7 P Y 9 P
`—_� �r� �O�t ��t ��h Type:; ubmersible ❑LS.Turbine �'.Reciprocating �Jet �]
"�st��'� �' � ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑Yes o
VARIANCE
r
Was a variance granted from the MDH for this well? �Yes o TN#
s WELL CONTRACTOR CERTIRCATION �
This well was drilied under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to ihe best of my knowledge. f
Use a second sheet,if needed. �
REMARKS,ELEVATION,SOURCE OF DATA,etc.
Ibn 5todola Well Drilling Co,. Inc. 1691
Licensee Business Name Lic.or Reg.No. �
._._.- -.f f�f ^�:��.
r�Ettfi� , �Sr��enta ve Signafur � Ceriifie ep. o. Date
Rt)b S#Of�OlII
LOCAL COPY 8 2 3 4 � 2 Name of Driller
ID#52603 HE-01205-15(Rev.6/13)