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• M/NNESOTA UNIQUE WELL
<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
<br /> CountyName WELL AND BORING RECORD � �`+�} .
<br /> Minnesota Statutes,Chapter 1037 ��� " �� �
<br /> 1 Nl�T1iZ� �t3
<br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> 4rono 217 ,, "
<br /> GPS DRILLING METHOD
<br /> Latitude degrees minutes seconds
<br /> LOCATION: :` ��Cable Tool L_�Driven . �.Dug
<br /> Longitude degrees minutes seconds
<br /> I i/+uger ,�Rotary �_ ]Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number �: '
<br /> ,�t�� �, � . DRILLING FLUID WELL HYDROFRACTURED? '���Yes �No
<br /> �}�;
<br /> Show exact location of well/boring in section grid with"X:' Sketch map ot well/boring location. From ft.To ft.
<br /> Showing properry lines, — —
<br /> : road buildings,an irection. USE
<br /> rv � � �Domestic ��Monitoring ❑Heating/Cooling
<br /> � ; ; ; � .,�„�,�''��--� ' •-�+y��'4� � ' . ' 1 Noncommuniry PWS L,Environ.Bore Hole �'Industry/Commercial
<br /> --'-- ---`-----` - ---'-- J
<br /> �� � � � � �,�yV I_�Community PWS !�..Irrigation ❑Remedial
<br /> --�--- --�------;-----�— `� �_j Elevator r;Dewatering �J
<br /> �� w ; ; ; ; e T ,_,_,,._,.,. CASING MATERIAL Drive Shoe? ���Yes j�No HOLE DIAM.
<br /> i__ �
<br /> . --;--- --�--- --�-- ---'-- f� Threaded �.;Welded
<br /> � � �Steel []
<br /> V , , , , h Mile
<br /> , , , , � I;�Plastic ❑ _
<br /> � --�-- --�--- --�-- ---�- �
<br /> CASING
<br /> � � S � � Diameter Weight Specifications
<br /> . �i M;�e—� � � in.to �� ft Ibs./ft. . _._ �//{-7n.to�ft.
<br /> 2
<br /> �� in.ro ft. Ibs./ft. �4 in.to���ft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME .
<br /> in.to fi. Ibs./ft. in.to ft.
<br /> � �� � �� OPEN HOLE
<br /> Properry owner's mailing address if different than well location address indicaled above. SCREEN .___ .
<br /> Make__ �'� . From_ ft. To ft. ��
<br /> ; ; 75{� t��ashic��ton Ave S TYPe stsinless st1. o�am _ _.. __
<br /> ��y(Z'c'�� �� J J�i�9 SIoUGauze__..�St�,L _ _Length�}t i_}__�,�.___ _ _
<br /> Set between_ ft.and ft. FITTINGS_ � w
<br /> STATIC WATER LEVEL
<br /> Measured from
<br /> Cc��, fL[id'Below � ]Above land surface Date measured
<br /> � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> . �� ft.after � hrs.pumping -T� g.p.m.
<br /> �� WelUboring owner's mailing address if different ihan property owner's address indicated above. WELLHEAD COMPLETION �y f������
<br /> �Pitless/adapter manufacturer_Wi�1_ _ Model .._
<br /> � 'Casing Protection _ .. _____._ _ _�Q12 in.above grade ';
<br /> '.l�At-grade(Environmental Well and Boring ONLY)
<br /> . GROUTING WFORMATION
<br /> G olu9ma eriaf's��a�aTcement �Bentonite '�oncrete I_]"bther_ � �-
<br /> l'�1ttIL8t ���. �Q �7 _ — 5
<br /> To ft _ ❑Yds �L,Bags
<br />�,. HARDNESS OF From_ To ft. �Yds. �L Bags
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO .,
<br /> From To ft. '�i Yds. ��;Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> r �""'. r�� �..,�.
<br /> ��� �t...i___feet `t.._� direction -'�---��'ty
<br /> Well disinfected upon completion? es �]No `
<br /> `. PUMP
<br /> r,Not installed Date installed +...,� -� � - -:a�_1 � � _ _____
<br /> $� Manufacturer's name
<br /> "'3
<br /> .... Model Number HP�����Volts ������'
<br /> Length of drop pipe .��✓� _.ft. Capacity g.p.m.
<br /> Type:l� ubmersible ���-�LS.Turbine ❑Reciprocating �,]Jet ,.J
<br /> ABAN ONED WELLS .
<br /> Does property have any not in use and not sealed well(s)? '�,_,�Yes o
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? `'.Yes o 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 irue to the best of my knowledge.
<br /> Use a second sheet,if needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc.
<br /> Aoci Stodol�We11 Driltin�; Co.. Inc. 1691
<br /> Licensee Business Name - �. Lic.or Reg.No.
<br /> .���'� " /�- /
<br /> .-''� � �==�_ �
<br /> er ed Representative Signature'� Certified Rep.No. Date
<br /> LOCAL COPY f I U t.� J :� �iriC SLOC�OI.8_ — - —
<br /> Name of Driller
<br /> IC 140-0020 HE01205-12(Fev.12/OS)
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