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, MINNESOTA DEPARTMENT OF HEALTH M�N AEND BORIN�G NO. ELL �LI.O^BbRING LOCATION �o��,Y Name WELL AND BORING RECORD �TIt2e in Minnesota Statutes,Chapter 103I � 5��, �8 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Ororx� i 17 �, ,, �, ` K. GPS DRILLING METHOD LOCATION: Latitude ___ degrees minutes seconds Longitude degrees minutes seconds U Cable Tool ❑Driven ❑Dug ❑Auger �Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �� 145 �ith Ave � DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in se tion grid with"X" Sketch map of ell/boring location. �ter From ft.To_ ft. � Sho ing property lines, � N roads,buildi.gs,.and direction. USE �li Domestic ❑Monitoring ❑Heating/Cooling � � �en� � .J__ __�__ ___�_____:__ '"._ - ❑Noncommunity PWS ❑Erniron.Bore Hole ❑IndustryiCommercial � � ❑Community PWS ❑Irrigation ❑Remedial - - - - -- - - - � .r ❑Elevator ❑Dewatering ❑ � _�-- - i- - -`- - -' - � W � � � � E � � �,� ` ASIN RIA OLE DIAM �, ; ; ; ; T � �� ., C G MATE L Drive Shoe? ❑Yes ❑No H � ` --;-- --�-- --F----.-- I '� ❑Steel ❑Threaded ❑Welded , , , , Mne � • ,�,/ L . � , , , � � � � -- ,yy Plastic ` --�--- --�-----�-- --�— , .:,� ;. 1 � CASING � � S � � `ti, � Diameter Weight Specifications ✓ ✓ L �n �—i nniie� �� `� in.to �52 n. I'�s./ft. �� in.to�ft. PROPERTY OWNER'S NAME/COMPANY NAME,'. in.to _ft. ____Ibs./ft. __ �in.�"O ft. Phili �D�Ci V in to ft. Ibs./ft. in.to ft. ,, , Property owner's mailing address if difterent than well loc ion address indicated above. SCREE OPEN HOLE Make�� From To ft. � � a� Type ��[i e�A�t Diam. SIoVGauze .�ZC7 Length �� ♦ �}� Set between ft.and R. FITTINGS » � STATIC WATER LEVEL � Measured from — ft.�Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUM*PING LEVEL(below land surface) i� ft.after � hrs.pumping 35 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ' , Pitless/adapter manufacturer 1 }..��'-'�—�Model a ❑Casing Protection �12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted �Yes ❑No Grout materials ❑Neat cement�Bentonite ❑Concrete ❑Other From�To�_ft. _�_ �]Yds. �'Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From�_To�s�_ft.��'�is. �]Bags MATERIAL From To ft. ❑Yds. ❑Bags NEAREST KNOWN SOURCE OF CONTAMINATION �-'18 �Z�O�T '"�� feet �'^' direction `�—+—�" �_'x t_ � Well disinfected upon completion? �Yes ❑No ._.,eS... �� C ra PUMP ? ❑Not installed Date installed C.P � ;� .'r � L � . r8�j � ManufacturePs name � ��r-� Model Number HP�Volts � �.� ti�.! C� Length of drop pipe �('J v ft. Capacity_ g.p.m. �� T � � Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ 1 ABANDONED WELLS Does property have any not in use and not sealed well(s)? [�Yes,,_ry No VARIANCE Was a variance granted from the MDH for this well? ;]Yes�.'No TN# 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,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. �'j Stt�dvla t�kll Drilling Co�� 1�• 1�1 Licensee Business Na Lic.or Reg.No. , �� r �,i<;�� -G 7 rfi ,epresentative Signa [e- Certified Rep.No. Date 7 5 0 6 3 8 Name of Driller � �� LOCAL COPY -— -- IC 140-0020 HE-01205-10(Rev.6/O6)