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r � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. � County Name WELL AND BORING RECORD �,qt Qn �nnepin Minnesota Statutes Chapter 1031 � �� `�' �-% r Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed .� Q�0[I� }�1.7 Z� 7 ,/< '/< '/ 2�1 n �.1"'12�� GPS DRILLING METHOD LOCATION: Latitude degrees __ minutes __ seconds _, .� r�Cable Tool i] riven � '�.Dug Longitude degrees minutes sewnds �� Auger �otary ❑Jetted Hous'e LNumber,StAree,,t�NamTe�,City,aAnd Zip Code of Welt�Lo�ca/tion or Fire Number �Cl 1,7Y� N [iL`II VL� VCOT�I �S.7Vy DRILLWG FLUID WELL HYDROFRACTURED? ❑Yes o Shop exact location of well in section grid with"X°. Sketch map of w I location. �teC FROM ft.TO_ ft. Showing pro erty lines, N roads an bw�s USE - '�Monitoring ❑Heating/Cooling ; , i '��DomLstic �'Environ.Bore Hole ��'_I Industry/Commercial --- -- I��,_ � I.]Noncbmmunity PWS � '�Irrigation l Remedial Comrtiunity PWS ❑Dewatering `;_ : '-""'' ` `- � CASING � HOLE DIAM. W � E -i !. Drive Shoe? �]Yes �No ._� ; T ' hreaded u elded ,. -�- - � � I —. --� � i S �I T teel �'W PI C '/Mile _ ..` as Ic _ _ 's - -- 1 ` �+' t� �f t p �� j�- ` CASING DIAMETER WEIGHT > c S � � � -/�_in.to_�yL __ Ga�l Ibs./ft. g__in.to�. . �-1 Mile—� „�,I �, 2 in.to_ ____-_ ft. Ibs./R �in.to��t. PR�O+PERTY OWNER'S NAME/COMPANY NAME in.to tt. Ibs./ft. in.to__ft. � �.7L-.OLC �e1S SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make ��[f�� FROM _._ ft. TO ft. ,.,. TYPe ._- tY�'" _ --- Diam. ,' SIoUGauze__�VbSt—_-- _Length�� _ Set between�nt ft.and_ �_�__ft. FITTINGS� ~ STATIC WATER LEVEL � `�� ____.� ft.�below �above land surface Date measure��_-�� , PUMPING LEVEL(belo�land surtace) WELL OWNEF'S NAME/COMPANY NAME � __�� ft.after 2_ hrs.pumping � g.p.m. WELL HEAD COMPLETION �y� - Well owner's mailing address if different than property owners address indicated above. �pitless adapter manufacturer_11111t�'117flteC .. M�o/del__ _ '�Casing Protection _ . __ ./'�12 in.above grade ��.,__j At-grade(Environmental Wells and Boring ONLY) r GROUTING INFORMATION ,� Well grouted �Yes ��No � � Grout material �� Neat cement , I Bentonite 'L;,Concrete �High Solids Bentonite � i from�. to�ft. _�_ '._I yds. �bags from�__.to l4b ft.[�$�j]L$�_��. _��bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. �I_i yds. �`��bags MATERIAL — -"-"-- NEAREST KNOWN SOURCE OF CONTAMINATION � rt 11� �� V �3 �.) ...""' feet -- '�-' direction -.��X�.a ,,._:5:�.,��e Well disinfected upon completion � Yes �_�No ~ PUMP ra soft 13 t30 _ - �_Not installed Date installed __ __��_ f ra $Qr� � 103 Manufacturer's name �C1�t�t ___ ____ _ 1 Model number _.__ ___HP 1 Volts `� f � i88 Length of drop pipe___r n� _ft. Capacity__ . . g.p.m. Type:��, .Submersible �-��LS.Turbine [ �Reciprocating �_�Jet ❑ 1� ZO ABAN ONED WELLS Does property have any not in use and not sealed well(s) ❑Yes � o � VARIANCE >e 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. Useasecondsheet,ifneeded �Z �18 �1�. D=iAli� �� I11�.•• 271T2 3 REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. Auth��/, j� .. �__ �;��t=� _'_ 12-1 S-Q3 _ ntative Signature Date Ctn�ck Mooce 11-i2-03 �� 4 g� Name of Driller Date _ ; LOCAL COPY He-o,zos-oa�ae�.sioz� � IC 140-0020