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_� WELI L�CATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WE our.ty�ame WELL AND BORING RECORD � ��'�-� Minnesota Statutes Chapter 103/ 5 8 0 4 0 6 Township Name Tow sf�ip No. Rangg,y,o. Section No. Fraction WELL DEPTH(completed) Date Work Completed L'Y'.`i'tt� � 1I LJ I's[1 �$�� n. fi—�—�� v, i. v. House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 3�.`��•' ��i�.r�t �11� �,U�Q �1. �?�1 �'�� ❑ Cable Tool ❑ Driven ❑ Dug � ❑ Auger O Rotary ❑ Jetled Show exact location ot well in section grid with"X". Sketch map of well location. ❑ j Showing property lines, � roads and buildings. DRI�LING FLUID � i N � I I I I � � I I I I L 1(�� USE ❑ Monitoring O Heating/Cooling i i i � f�Domestic ❑ Communi PWS ❑ Irrigation h' ❑ Industry/Commercial ; , ; i � Noncommunity PWS ❑ Remedial yy E� �. ❑ Test Well ❑ Dewatering ❑ i i i i i i i -r CASING Drive Shce? ❑ Yes ❑d+lo HOLE DIAM. VzMna � i _L i_ I t � ❑ Steel ❑ Threaded ❑ Welded -i -i- i i � ! v) �iPlastic ❑ s �1 Mile� � �1 CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME � in.ro � ��ft. Ibs./ft. � i��t ��{ �C.3�..''T'� L1:rxi.Cj �� (, � �.t�� t�. in.to ft. �bs./R . Property owner's mailing address if different than well Ixation address indicated above. in.to ft. Ibs./ft. in.to_ft. L_.'..�i�I S E3ZCLC�'�sG^�'�.I,.-r:i ��:y'�{� SCREEN_��_ OPEN HOLE Make from ft.ro ft. - S�lOY'�WCX:f�� 1. J�J��. TYPe � �il E�SS �E.'t-_'i Diam. .-n SIoUGauze ��l�}�,.` Length �S! Set between ��ft.and i r!f;ft. FITTINGS: �(i� �{ :�u STATIC WAT LEVEL WELL OWNER'S NAME � fl. Lj�below ❑ above land surface Date measured �3 �� PUMPING LEVEL(below land suAace) Well owner's mailing address if diflerent than property owner's address indicated above. ft. after hrs.pumping g.p.m. WELL HEAD COMPLETION C�Pitless adapter manufacturer ��r Model ❑ Casing Protection ❑,l�in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? C�Yes ❑ No HARDNESS OF Grout Material ❑ Neat ceme . O Bentoru g-, ❑ Concrete d�k�igh Solids Bentonite GEOLOGICAL MATERIAIS COLOR MATERIAL FROM TO `�: 3E: L from to � tt. ❑ yds. �bags � i -y i from to ft. ❑ yds. ❑ bags 7�t�i1/Clay $lar.3c� ::��r S i 1.�. from to ft. ❑ yds. ❑ bags NEAREST O�yyN SOURCE OF CON�MINATION �j �^ � �s2 c:�,'E.'�. t}.�`��Y � �.;+�� feet -� �J✓1 l'� direction '..��.J�1� Well disinfected upon completion? O}�es ❑ No :��r��/fine tc tn�:c `T��n �r3 l�t� , :� ,�J ., PUMP ^� � ^r ❑ Not installed Date installed !^�'"`�� , `J�i.�T�.��2.3.Z1t� �C? T�1 "�'t'1T3 3 � t{;; �� Manufacturer's name �tit"lyj�� Model number ��1��L� HP_.�_ Volts �3{� - Length of drop pipe j U4� ft. Capacity �f'• g.p.m. Pressure Tank Capaciry }i�{��1(^rj), (��,].V Type: o;Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Dces property have any not in use and not sealed well(s)? ❑ Yes LI�o VARIANCE Was a variance granted from the MDH for this well? O Yes O}�!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. The information contained in this report is true to the best of my knowledge. �� :7�� {.�i.� ��.. �/� � Licensee Busine s Name Lic.or Reg.No. /! ,� �s^��y�� 3"�—��3 7 ,�`�_ � Authonzed Representative Signature Date C�Ll�k �:�C�Yt� €3--�—r9fi (''� �a Name ol Driller Date � �� - � ' � `"�"'�� `� �� '� ��''# HE-01205-05(Rev.1/95)