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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. ��- CountyName � WELL AND BORING RECORD Q � ��i�'�F�r� Minnesota Statutes Chapter 103/ � v 0 � � � Township Name Township No. Range No. Section No. Fraction WELL DEPTH(comple[ed) Date Work Completed n. t�rr��c 31% ;:i ua ,�. ,�. �. i�`� ' �-�;- 9i House Number,Street Mame,City,and Zip Code of Well Lceation or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Du !_��1�"' :�C'T�l�rSf?� L�ne �T�C�I� T'!� `?;:.i.`'.� ❑ Auger ❑Wotary ❑ Je ed Show exact location of well in section grid with"X". Sketch map of well location. ❑ L j� � S wing property lines, f � r ds and buildings. DRILLING FLUID N �� ta:i i t:� � � i � '` , t. __ ___ ___ _�' � �'' USE ❑ Monitoring ❑ Heating/Cooling i i � i X J�,j Domestic ❑ Community PWS ❑ Industry/Commercial ' _i_ _�_ _�._ _i_ ❑ Irrigation n, i � i i ❑ Noncommuniry PWS ❑ Remedial ,� y,r E ❑ Test Well i � � � ❑ Dewatering ❑ . i i -r -� ��ZM,� CASING Drive Shce? ❑ Yes ❑ No HOLE DIAM. �` 1 ❑ Steel ❑ Threaded ❑ Welded —� � —L— —�— i i i i �,Plastic ❑ S �-1 Mile-� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME `' in.to � �� ft. `�DK.i� Ibs./n. % �� .�{�� C:h��_E'_:a C:11EiCt C:U. in.to ft. Ibs./ft. �_��{oiL��j' Property owner's mailing address if different than well location address indicated above. in.to fl. Ibs./ft. in.to ft. �8�G WtJC}�fG1cT�E DZ'�_V-G' SCREEN �� OPEN HOLE $�ICiCtL21,312r''y� MII. J�1 L.� Make � from F ft.to n. Type +✓��.1.I1.�.E�',r''S.`'.� acs't�f.-'�. Diam. Slot/Gauze ��/�i; Lengih Set between ��__ft.and�t u�,Sft. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME �� ft. �below ❑ above�and surface Date measured �_`�•`t'} � PUMPIrjG LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. � ��J ft. after j hrs.pumping •=t'' g.p.m. WELL HEAD COMPLETION ❑�iUessadaptermanufacturer ��31.F.�Wc',.t�'.� Model - ❑ Casing Protection OX12 in.above grade ❑ At-grade(Environmental Welis and Borings ONLY) GROUTING INFORMATION Well grouted? C�Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement O�entonite ❑ Concrete ❑ High Solids Bentonite MATERIAL from � ro=��_R. �_ ❑ yds. C]�bags �,,�1� f��# r a from to ft. ❑ yds. ❑ bags from to ft. ❑ yds. ❑ bags NEAREST/KN�0/1dAl,$OUFCE OF CONT�91dlNATION �("� ^^��`` /`�, �1 r3�' Y��.l.��•Sn `� � L�} �//=�' feet --'�' G%✓�� '"'`��Y direction pe Well disinfected upon completion? �Yes O No CL:.�y Gx�n� ��; �_� PUMP ❑ Not insta�led Date installed �� f S�3nci-G��ii el 7�:I1 �� `, � INanufacturersname ta�ZT;t:?�OZ Model number HP_��_Volts ��(�i Length of drop pipe�L,� � ft. Capaciry t t g.p.m. Pressure Tank Capacity �L Type: �Submersible ❑ L. .TuP6ine -Reciproca mg �Jet ❑ ABANDONED WELLS Dces property have any not in use and not sealed well(s)? ❑ Yes Cl�lo VARIANCE Was a variance granted from the MDH for this well? ❑ Yes ❑�o WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. 7he information contained in this repon is true to the best of my knowledge. L�c:;:v �`I:'UI}CiLr� tid�LL I?�tILLZIkiG CC), , TAIC. L�censee Business Name Lic.or Reg.No. � " 211 i� r`�J � ��'� �-�-�i Authorized RepresentafiJe Signature Date CZ'�r 1�E'1�?�r �;_.�;__� i � ,.� r � y.. Name olOr/ller Date a . . . .. : �.. °�.� �.. � ..�� s.,,.�4 �- HE-01205-05(Rev.1/95)