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_ _ _ .�� � * MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. CountyName WELL AND BORING RECORD / -� r-� {.�f � �^q�, ��nQe itl Minnesota Statutes,Chapter f037 F t `-- V � o✓ Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED I18 23 33 I� 1�W, S�, f� GPS DRILLING METHOD LOCATION: Latitude _ degrees minutes seconds _ Longitude degrees minutes seconds L Cable Tool �Driven ��i Dug ,_',Auger �Rotary _.Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �' ZVW S�1VE�C V��I uL �ra7o 5535 DRILLING FLUID WELL HYDROFRACTURED? �]Yes ��i,iVo 4� 7` Show exact location of well/boring in section grid:with"X" Sketch map of well/boring location. I]G[lt�t� From ft.To ft. ;� f. Showing property lines, — N � , roads,buildings�and direction. USE i�omestic , ��.�. � ' ;,M _. ❑Monitoring ❑Heating/Cooling � � � � \ n� -- ---- -------- - \� � ?. _ ;__ _ J � : [, oncommunity PWS [�Environ.Bore Hole ❑Industry/Commercial -, � � ; ; ..,' r'��Eommunity PWS _�Irrigation ❑Remedial ' ' _-�_ ' '?••� � � r �I levator �]Dewatering ❑ � __ ____'____ ____ __ � p _ W , , , , E T �� CASWG MATERIAL Drive Shoe? ��Yes �'No HOLE DIAM. � � � 'e' �;' . "'�'"'"'�__' _"�_'___i__ .. t,� . . I [j Steel �_,Threaded ❑Welded • , , 'hM�ie � _"-"-' Dameter� Plastic Wei ht� � -- - 1 � � S � � '�. � g Specifications , .,...,- t Q �--iMile—� �.� ` � in.to l�-+ ft. �� Ibs./ft. �� y�—in.to� ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. -'` in.��ft. �=t �� ._in.to____ft. Ibs./R. in.to tt. Property owner's mailing address i(different than well location address indicated above. SCREENF.r�� OPEN HOLE Make �R)lAl:tt7[2 From ft. To ft. � Type $a.ain��8$ .�41 Diam. ,' � SIoUGauze__��_____. Length�� '� � Set between ft.and ft. FITTINGS �„ � � STATIC WATER LEVEL Measured from _ft.�Below i_''�Above land surtace Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) A �� ft,after__ v hrs.pumping `� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION , . ;�"Pitless/adapter manutacturer ��'� ��-_, � %��a.Mptiel_ ��Casing Protection___ j�12 in.above grade I�I Ahgrade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted ',�Yes I �No Grout materials ��Neat cement ��entonite [j Concrete [�Other From_�'" To_��_ft. �_ �;Yds. ��Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To_ it �',Yds. �J Bags MATERIAL From To ft. ��Yds. ]Bags NEAREST KNOWN SOURCE OF CONTAMINATION C�$ � el�� t �� i� �.f}.� feet �✓ direction �-� �L[.�.„��__type Well disinfected upon completion7 es U No ` ci ra aoft 18 7(1 PUMP ` 'Not installed Date installed �/ � t=`-�� .1 j a� Y �+�+ � ��t �� O�Manufacturer's name C*g � �`t ��O ��Q Model Number � � j- HP�Volts �,�,� ��'�7 1 � Length of drop pipe � �/ 1 fl. Capacity g.p.m. �� rg �tt 1�O 1�1 Type: Submersible [j LS.Turbine ❑Reciprocating ;]Jet ❑ L 1 1 x ABAN ONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes '�� No VARIANCE Was a variance granted from the MDH for this well? j__Yes ' �No TNH 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. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. ik�n Scodola W�11 Dc�tiir� Co,. iric. 26�1 ------------- — --- —_ � Licensee Business Name ��-�� Lic.or Reg.No. � /� 1� . r� � r� presentative Si nat Certified Rep.No. Dat� C�ttC�C �'dOOr� LOCAL COPY ��O� � 3 - Name of Driller IC 140-0020 HE-01205-11(Rev 3/07)