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<br /> JG LOCATION
<br /> MINNESOTA DEPA�TMENT OF HEALTH MIN AEND BORIN��G NO. ELL
<br /> WELL AND BORING RECORD 7 919 7 6
<br /> � Minnesota Statutes,Chapter 1037
<br />.. ,,,,,,,,,,,,,,,.u,,,., Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED �
<br /> vrc�r �1T 23 a9 s�e t� �c �,, Zas " fr--I
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds
<br /> Longitude degrees minutes seconds �Cable Tool ❑Driven
<br /> ]Auger ,�lotary
<br /> House Number,Street Name,City,and ZIP Code ot Well Location Fire Number ❑p�her
<br /> �Sl� l�Vt.�.il � iTL O�� �S� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes . o
<br /> Show exact location of well/boring in section grid with"X" Sketch map of welUboring location. �' �t"""�tC From ft.To ft.
<br /> Showing properry lines;'
<br /> N buildings,and direction. USE �Domestic ❑Monitoring ❑Heating/Cooling
<br /> __j__ __!�_ _._�_____�__ "- � '�,_I Noncommuniry PWS ❑Environ.Bore Hole ❑Indus[ry/Commercial
<br /> �C.f ,J Community PWS ❑Irrigation ❑Remedial
<br /> :� __�.___; �- ---�-- �r: ,'� ❑flevator ❑Dewatering ']
<br /> , ; f * � I' `�� � yy MATERIA� Drive Shoe? L.��Yes ,,�?No HOLE DIAM. _� '
<br /> w e CASWG
<br /> i - I.J Steel ❑Threaded ❑Welded
<br /> . , , , , h M e lastic ��_J
<br /> --;-----.--- ---.-- � 1
<br /> CASING
<br /> � � S � � Diametg r 4 +� Weight Specifications p
<br /> F--1 Mile-� � " in.To j�r ft. Ibs./ft. --��a--��in.To �v ft
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. _' in.To��ft .f�
<br /> �'f___'� � _ in.To_ _ft. IbsJft. � in.To ft
<br /> i'![1(Z
<br /> OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated above. SCREEfJ�_i�_ _
<br /> �lf�s
<br /> Make_���}���� From__ ft. To ft. -
<br /> � Type g�"�j'•`�" � Diam.
<br /> �� SIoVGauze_ __�_.. __ _ Length� � �� ��
<br /> Set between_11� _ft.and_��ft. FITTINGS� �
<br /> STATIC WATER LEVEL Measured from
<br /> �e' �___. ft.�elow ��Above land surface Date measurQd � ��'
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surtace)
<br /> � ��,rj'_ ft.after_____ _Z hrs.pumping _ ___g.p.m. y
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
<br /> �Pitless/adapter manufacturer����� _ Model
<br /> ❑Casing protection_ `�f'12 in.above grade
<br /> ❑At-grade '�Well House ❑Hand Pump
<br /> GROUTING WFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
<br /> Matenal ����.,�u,4��prom ��/� To �*O ft. � __ ❑Yds. ❑Bags
<br /> Matenal �6�.�1. ir�� .7�.i To l�� ft. � ❑Yds. ❑Bags
<br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags
<br /> GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Dnvencasingseal From___To _Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> .. L � ' ��.r-�h.-s.. ,a......r� Y''°�..
<br /> � � v *_..�� feet .'`j �"'� direction �type
<br /> Well disinfected upon completion? ,�Yes ❑No
<br /> � � � :..�
<br /> `►� I PUMP
<br /> [I Not installed Date installed_ �,j��7___ _
<br /> C Manufacturer's name .7G.'L7liGl�
<br /> _Y,� Model Number HP 1�1 Volts.4.7V
<br /> �u Length of drop pipe �� _ ft. Capacity g.p.m
<br /> Type:,�Submersible ���, 'I LS.Turbine ❑Reciprocating �]Jet ❑
<br /> ABANDONED WELLS
<br /> Does property have any not in use and not sealed well(s)? ❑Yes No
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? ❑Yes,�No TN#
<br /> WELL CONTRACTOR CERTIFICATION ��
<br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
<br /> The information contained in this report is true to the best of my knowledge.
<br /> Use a second sheet,if needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc.
<br /> I'aon Stodol� wel.l Drilling Co., Inc. 2691
<br /> __ _ -- __ _ _ _ _ _
<br /> Licensee Business Name Lic.or Reg.No.
<br /> 6-29-l2
<br /> ti d rese tativeg, na e Certified Rep.No. Date 6
<br /> j ,
<br /> �.
<br /> LOCAL COPY 7 919�6 �b ����$ —
<br /> Name of Driller
<br /> IC 140-0020
<br /> HE-01205-13(Rev.11/10)
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