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r E - WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. CounlyName WELL AND BORING RECORD ,� Minnesota Statutes Chapter 103! � � �m '�� ' Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed fl. �,. ��. �,. 6� 7-17-OZ House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILIING METHOD [] Cable Tool ❑ Driven [] Dug I-1 Auger �Rotary ❑ Jetted ' Show exact location of weli in section grid with"X". Sk�tch map of well location. f 1 _ ..__ f N_� q j��y Showing property lines, �bvitdings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �'NO N �entonite _ � � �_ ��uj z �� FROM n.to_ n. ;- -;- -,-- -, �u .,�r USE ❑ Monitoring ❑ Heating/Cooling i i i i .___- _�� `,Domestic ❑ Communit PWS _i_ _a_ _�_ _i_ ❑ Irrigation Y ❑ Industry/Commercial i � i i ❑ Noncommunity PWS ❑ Remedial yy E T ❑ Environ.Bore Hole f 7 Dewatering ❑ :. i i i i I -- -r -7- -r- -r � i i i ��M e � CASING Drive Shoe? �Yes ❑ No HOLE DIAM. � z . _i i i _�_ f �1 Steel �'Threaded — ❑ Welded - � � � � 1 ❑ Plastic �� S �—,M,�e� � � �,t �� CASING DIAMETER WEIGHT ` PROPERTY OWNER'S NAME �____ in.to_��'�ft. ��___. _--Ibs./tt. �__in.to�_�ft � D�Q� 3.h��$QQ -- in.to— ft Ibs./ft. �T! ��V � Property owner's mailing address if different than well bcation address indicated above. .,... ..in.to ft. ______.__ Ibs./ft. in.to__ ft. i: 25h2 E 9800 S�LtC� SCREEN OPENHOLE Sanap� VT C}+4Q(3� Make.�flhjj$�j; from ft.to ft. ./ � TYPe—$��_�—_._.—Diam. �---- Slot/Gauze _•p.�__. Length�_}.____�_� c Set between v ft.and ft. FITfINGS� STATIC WATER LEVEL � WELL OWNER'S NAME ��__. - ft. C�Delow ❑ above land surface Date measured 7—i 7=� PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. __2��_ ft. after_�a.�_hrs.pumping�D._. _g.p.m. WELL HEAD COMPLETION � ` �Pitless adapter manufacturer Model � . �i�l��-f!i�7-8�t..'� - — _ -❑ Casing Protection _ __ __ _ �2 in.above grade ❑ A!-grade(Environmental Wells and Borings ONLY) �` GROUTING INFORMATION Well grouted? �Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement �] Bentonite ❑ Concrete f�CHigh Solids Bentonite MATERIAL from__Q___to�� ft. ��___ ❑ yds.�/bags � from_ to_._ _ft. ___ ❑ yds. ❑ bags t�'�}$Q��, 1}�,$C� $Q�t Q 3 from._ to ft. _ ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION Cl�y gray soft J 9d -- ,� "�.�- feet _.____.� _diredion __ type Well disinfected upon completion? t�'�Yes ❑ No clay/sand gray soft 90 I6fl PUMP : ❑ Not installed Date installed__.__ _�d�� L�.C1� sand gray ��ft �6� 170 Manufacturer'sname __ �C��.4_ — — _ Modetnumber��.,J��_��HP .�� Volts . _ � clay/sand gcay soft 17f? 2S7 Lengthofdroppipe s_��_ _ _ ft Capacity _ __ gp.m. ` coarse Type: ' ubmersible �_ lS Turbine ❑ Reciprocating ❑ Jet ❑ . sandstc�ne xhite �oft 257 268 ABANDONED WELLS Does property have any not in use and not sealed well(s)? C Yes C�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes o TN# WELL CONTRACTOR CERTIRCATION i= = Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. ��" The information contained in this report is Vue to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodola Well Drilling Co. , inc. 2 172 � icen �e Business Name . L� -or Reg.No. �� _ i L%�S�' ut orized Representative ignature ' �'�at��_�� Chuck Moore 7-i7-02 ---- --- � �q Name of Driller Date LOCAL COPY `�-� � r �� T HE-01205-07(Rev.2/99) IC#140-0020