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� �_�. WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BOR/N'�G NOWELL ' co,;,,tYN-ame '' WELL AND BORING RECORD � r: H�er�epin Minnesota Statutes,Chapter 1037 P � �� 7 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Ot'Cl[l0 117 �� Q? ,i y, y, n _ GPS DRILLING METHOD LOCATION: Latitude degrees _ minutes seconds Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug ❑Auger T�Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � � � 31b9 Nocth Atm �r, vLV�iV SS.7V'i DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X" Sketch map of well/boring lo ationl� �t�ute From R.To ft. Showing propert line � .; N , . roads,buildings,and dir ctio ' USE �dt Domestic �_j Monitoring ❑Heating/Cooling � � � � � � �- C 'ci . __;__ __,___ ___�____i__ ❑Noncommunity PWS �]Environ.Bore Hole ❑Industry/Commercial • ��'�"� � ❑Community PWS �_.]Irrigation ❑Remedial � , � � � ; I I I �� ` '-'--- '-i--- ---`'----t- � - � ❑Elevator LJ Dewatering ' w � � ; ; E CASING MATERIAL Drive Shoe? �Yes ❑No HOLE DIAM. �� --�--- --�--- ---�-----:— T �Steel ❑Threaded ❑Welded � , , , , Miie 'h � ' I ' I ❑P ❑ --:--- ---.------�-----.-- 1 lastic ; ; � � i CASWG S �� Diameter Weight Specifications �1 Mile� •yFy �in.to�ft. 11 Ibs./ft. � in.to .7V ft. �j PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. _ �in.t�65 n. an lS1�83 in.to ft. Ibs./ft. in.to ft. � SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. 4,.� �O� `��y=� n��' �� y�O� Make �lAl$� From ft. To ft. A1 kSill D �1 Type ��t�i ral� � gt1 Diam. �! � 55�+ SIoUGauze ��ll n Length ,�� .F (�� Setbetween ft.and_�_ft. FITTWGS M STATIC YJATER LEVt Measured from 11� ft Below ❑Above land surface Date measured w WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �� ft.after � hrs.pumping `fJ g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION .p.. � �Pitless/adapter manufacturer L]��s��-x"i"'""""�`'�`� ❑Casing Protection �12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) GROUTWG INFORMp,T}ON Well grouted �'Yes ❑No Grout materials ❑Neat cement �Bentonite Concrete ❑Other From O To � ft. � ❑Yds. (�Bags HARDNESS OF From � To �� .natucal f�l,.�. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO From To ft. ❑Yds. ❑Bags NEAREST KNOWN SOURCE OF CONTAMINATION r cla Ilv� ieedi�n 0 22 ' - � ,�� _ . ° y � feet direction '� � type a� Well disinfected upon completion? �Yes ❑No �.+u-.��. ��v-��---� ; CI8 I� ��1� GZ 1ZO PUMP ^--� q �Not installed Date installed ��j /l( �"� ( ��[� silt/sand � .�ft ZG� 235 Manufacturer'sname `—�--�-�''�"� '-4'�'-' ` t C�8 /� �`t �� n�� Model Number HP � '� Volts �"�� a � L' ''7 Length of drop pipe !7 ! ft. Capacity g.p.m. � ��t�C, � �� q/Q ^LC Type: Submersible ❑LS.Turbine ❑Reciprocating [�Jet ❑ ��3 �� ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE d 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. ikm Stadola WE11 Drilling Co,. Inc. 169I Licensee Business Name Lic.or Reg.No. /� ��-�� rti epresentative Signat Certified Rep.No. Date 7 �o V lJ � Name of Driller J� �� LOCAL COPY --- -- IC 140-0020 HE-07205-70(Rev.6/O6)