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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NC CountyName WELL AND BORING RECORD �, ;� � g g H�� #� Minnesota Statutes Chapter 103! e.J � i � Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. Ocono 117 23 11 �. ,. ,. 22� 20-23-02 House Number,Street Name,Ciry,and Zip Code of Well Location or Fire Number DRILLING METHOD 1G2� Shoceline L� 1� �r�[1Q 5`391 17 CableTool ❑priven ❑ Dug y i-1 Auger ,,,�,"'/4 Rotary ❑ Jetted � ��, Show exact location of well in section grid with"X". �� Sketch map of well location. f7 _____ __L.._.__..___.._ C � Showing property lines, ____ -- .__ . _-------�------__—._-- � roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES�O N �vr _� � � �_ � I, ,�� /�-.�. wa t e r FROM---- --n to-----,t. ,- -;- -,-- -, '�/r �� USE � ❑ Monitoring ❑ Heating/Cooling i i � � Domestic ❑ Communit PWS _i_ _�_ _�_ _i_ �� 7 Irrigation Y ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w e� ❑ Emiron.Bore Hole ❑ Dewatering ❑ i i i i -- -- i _� r -r '/ZM1e CASING Drive Shoe? ❑ Yes No HOLE DIAM. _� _ i_ � _ _i_ � � ❑ Steel ❑ Threaded ❑ Welded - i i i i ` � .(�Plastic ❑ s / �-t Mile—� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME �tL _�_in.to____��_z ft. __ ? _(3� Ibs./ft. �in.to��ft. Keith Waters 4 [�.g$OC• _-- in to_.—_—tt' —.- _.—_ _ Ibs./ft. L� in tdZ�ek. V� Property owner's mailing address if different than well location address indicated above. _. ___in.to__ ft. IbsJft. in.to ft. p n 6 216 Bak e r Ad� �t e 1 1� SCREETN�_ __ _. OPEN HOLE Sd�n Frairie M�I 5534fi Makey�(jl1[1SO11 from fl.to tt. � TYPe_��evv-�-}cs----Diam. .—Z� SIoVGauze_... _Length _ • Set be[ween __ _ft.and__ __ft. FITTIN S: -- ;r STATIC WtATCER LEVEL WELL OWNER'S NAME y�_ ft.�elow ❑ above land surface Date measured �n+7�� 2 � PUMPING LEVEL(below land surface) Well owner's mailing address if diffeient than property owner's address indicated above. �_Z_Q_ ft. after � _S hrs.pumping � _g.p.m. S i '� WELL HEAD COMPLETION {,� � �(Pitless adapter manufacturer �1��C eW�t��Model C Casing Protection _ _ __,�/12 in.above grade - � AFgrade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material Cl Neat cement ❑ Bentonite ❑ Concrete �High Solids Bentonite MATERIAL from_._� to �_ft. _2_�_� ❑ yds. �bags from�A_to�_��ft. �8`"� ��c�.�7 bags clay bro�n $��t � 1 from____to ft ❑ yds. ❑ bags s6 NEAREST KNOWN SOURCE OF CONTAMINATION C��y/r�C�$ gray ��d�ul� 10 ZZ - -. .. � ,..� feet —. .._�� _. . _ direction �.—�i . --. -�yPe y . Well disinfected upon completion? I�'es ;�l No .,. 1y 4 1� SSlltl �L�$y SOl t 1�0 1 3 PUMP � ❑ Not installed Date installed .___..___..____��__,_____ �� � CZSy gCBy 1A4C1�llltl �.3� 2� Manufacturer'sname __ _��Lj@Q_t-QL__ _ __ —_.— —�--Q --- ;� Model number_ _ . __.__ _ _ _ HP __2.5 _ Volts_�.�j.�___ sand brown soft 208 22 , Length of drop pipe_._�_�._ ,___.______ ft. Capacity _____.______.__g.p.m. Type: ��. Submersible ❑ LS.Turbine C.7 Reciprocating ❑ Jet ❑ __ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes L�No VARIANCE Was a variance granted from the MDH for this well? C Yes �(No TNN_ ._ f WELL CONTRACTOR CERTIFICATION Use a second sheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. - REMARKS,ELEVATION,SOURCE OF DATA,etC. The informstion contained in this report is true to the best of my knowledge. j� � fl r__�.,c�_1 7�� --�-�� Licensee Busi ss Name =�, � iCc-or'Reg.�.�C�� r.� � � � �~___�.��=-E1�— — � Authorized Representative S�gnatur�'�� Date - Chuck �[ooce 10-23-OZ , Name oI Driller Date LOCAL COPY 6 7 7�9 9 HE-01205-07(Rev.2/99) IC#1a0-oo20