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v. OC 1TION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. Ccunl .. am�_ ' WELL AND BORING RECORD Q , lJ ��f;2'1t1��J1P. Minnesota Statutes Chapter 103f � v � � � � ` Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed .��.� C.;T�C,�n � �! i� U 1 1.�.� � e. j—.ii!--�% v. �a v. House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD )�:t} ��f�};i::3 Lli1C�F�s. ri�i�t:.� V.L�L��IiJr S� ❑ CableTool ❑ Driven ❑ Dug ❑ Auger �Rotary ❑ Jetted �� Show exact bcation of well in section grid with"X". � s Sketch map of well location. ❑ J�.f 6� Showing property lines, k, roads and buildings. DRILLING FLUID N t-�`s , .,_,.,,_ , - - ��, w�• . ,_. � � � , ; -,- -;- -, USE y, ❑ Monitoring ❑ Heating/Cooling i i i i X C] Domestic _i_ _�_ _�_ _i_ ❑ Irrigation � Community PWS ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w I I I I E� ❑ Test Well ❑ Dewatering p i i i i +�2M.�a CASING Drive Shce? ❑ Yes ❑ No HOLE DIAM. _� i i i_ � ❑ Steel ❑ Threaded ❑ Welded � � � � C�Plastic ❑ s � �1 Mile� - CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME --t%�"ti '� �i in.to [:�� ft. ::�DI'ZG � Ibs.ttt. 7 �r{��y g G T � c in.to ft. Ibs./ft. � rq � 7{ Hf3��"1� HC:�T��• _+ t�`� at. - Property owners mailing address if different than well location address indicated above. in.to ft. Ibs./tt. in.to ft. - SCREEN .7e7I�i ri c(;jl OPEN HOLE Make r*.,,_._..; .,,'t �,..� Sr�� from ft.ro fl. Type Diam. G SIoVGauze 4" � Length E� � Set between �'--� R.and L�^' ft. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME �� / � ft.4�3 below ❑ above�and surface Date measured J j Z'—� PUMPING LEVEL(below land surface) ':r: Well owner's mailing address if different than property owner's address indicated above. �=t� ft. after � hrs.pumping - g.p.m. WELL HEAD COMPLETION �E�itless adapter manufacturer ��l t ��t+�i 1 Model ❑ Casing Protection �] 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �i'Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement O�Bentonite ❑ Concrete l]{�igh Solids Bentonite MATERIAL from � to �� R. ��J ❑ yds.�] bags �� ``r �� '�, J `' .� from to ft. ❑ yds. ❑ bags �•1 l� ¢ trom to ft. ❑ yds. ❑ bags NEARE T K�fl SOURCE OF CO MINATIO�lf �7 1 7't- .. p .��:/�I� ('1�y ��'� j �'`..� �S'% .-�.- teet direction �*_type Well disinfected upon completion? ❑ices ❑ No .�ar�c! ��n S �%�-' 1 < . s�rrt i�� ,> PUMP ❑ Not installed Date installed �''-� � �a��4 G�.�.�.t, � } ;�': a '/ ": IrAanutacturer's name -"�; �' �� _ ,. .t Model number 1"� '� r' ' �' Volts � -� t � 1 1 - � kength of drop pipe ��J fl. Capacity � �' g.p.m. (.1�";}.r �7 L L� :J ! /+�t C....+ �; •- � Pressure Tank Capacity :� _ 1 i 7'i:� Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ � G'r;�v�l TC:�rt :a �'� �:�'. ` ABANDONED WELLS Does property have any not in use and not sealed well(s)? O Yes U�Vo VARIANCE Was a variance granted from the MDH for this well? ❑ Yes ❑;�o WELL CONTRACTOR CERTIFICATION Use a second sheet,it needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. The intormation contained in this report is true to the best of my knowledge. llC�P•. :.".[C:'L)tv:�j�� ,a,�:� Ll�.i.LLIt:G C�:, , ?�iC. Licensee Business l�lame ,-�Lic.orReg.No. `� '�'�i ,� ,-;�=''��/ / :��'� �, _.�, . ;_.S{;-^i t Authorized Represenfative Signature Date i��t. LF.�i.;_;r i-�v--y7 w� ,j � Name ol Driller Date _ �£ ',.+i �i F �, HE-01205-05(Rev.1/95)