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f� MINNESOTA UN/QUE WELL WELL OR'30RtNG LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. Gfwnty Name WELL AND BORING CONSTRUCTION RECORD g 18 012 Minnesota Statutes,Chapter f03I Town ip Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED 1�r0!10 7'1 T ' '�'3'�°' OE3 t+� 1SlW�/SW �/ 13h n ��S�l.�i GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven �Auger �d'Rotary House Number,Street Name,City,and ZIP Code of Well Location ❑Other j ` 4�YS SC. Ancl�ew� SC. OCOCIO 55364 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in sectioR,grid with"X:' Sketch map of well/boring location.� �� j�ter From ft.To (t. Showing property lines, — — � (� roads,buildings,and direction. USE � " Monitorin Heatin /Coolin � N , Domestic L� 9 ❑ 9 9 � ; , , , , i — _ __;___ __�_ _�__ ___;_ � Noncommunity PWS ❑Environ.Bore Hole U Industry/Commercial s f !]Community PWS ��Irrigation ❑Remedial --'- �-- --` `_ + � .,�/,,..,�•;,� �„ ❑Elevator �]Dewatering ❑ ' W ' ' E y� `�'� CASING MATERIAL Drive Shoe? ❑Yes�No HOLE DIAM. � ❑Steel ❑Threaded ❑ elded - '' _ ' ��Mile' ] �� ; ; �. � Plastic --�--- --�-----�-- -�— �I CASING , S `; �f Diameter Weight Specifications �_�M�_� � 1 + _�_in.To i�R ft. Ibs./ft. �_in.To��fl. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. IbsJft. �in.To��ft. in.To ft. Ibs./ft. in.To ft. Swanson �(k�w�3 OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN 13h� t��me1 �� Make Jahn� From ft. To ft. a`.�j CC )�/� TyPe��$ii^te$v��c�Diam. 7� A•sC�.li[l8� ��1 J J3�i�7 SIoUGauze � Length •s_ Set between ft.and ft. FITTINGS STATIC WATE L ' � Measured from �R ft. Below [J Above land surface Date measured � � WELL OWNER'S NAME/COMPANY NAME pUMPWG LEVEL(bel w land surface) �� ft.after `� hrs.pumping (}� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION [f Pitless/adapter manufacturer Model - ❑Casing protection ❑12 in.above grade [J At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cemeM,concrete,cuttings,or other) Matenal��i'tE From � To �u n. 3❑Yds. [�'Bags Material YISC�� 5(� To I2$ h. �vds. ❑sa95 HARDNESS OF Material From To ft. [',Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION sand cla �n}WTZ ��1�11 V Z� 1 ' '� feet a..i direction __��tYPe Well disinfected upon completion? Yes ❑No CiS' '`CA {tfediL�i{ �(1 7 PUMP _p L [�Not installed Date installed �R�_�` C�.t3 St"�t2C� �'C8 1!teCj�lNf1 ��7 ��? Manufacturer's name ,��] r- Model Number HP !.5 Volts $c'3itC1 RI�.X SO£t �� 2`� Len thofdro i e 1f°S ft. Ca acit m 9 PPP P Y 9P _ �tQC�r, �� nl �� Type: �Submersible ❑LS.Turbine [��Reciprocating []Jet ❑ ZA! G�f ABA DONED WELLS �LKi C la�' rE�� i�j 136 137 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? ❑Yes No TN# WELL CONTRACTOR CERTIFICATION r 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 sheeG if needed. REMARKS,ELEVATION,SOURCE OF�Tg�eCEIVED E D4n Stociola Well Drillin� Co . Inc. 16�?1 Licensee Business Name Lic.or Reg.No. JUM � .� 7�, � '',,�' � , ,. �F ,!';�,� ' _ ;-��'�,,�-� 2-25-16 ✓ f"F'"'- .f -�I�Oc ��9ep�esentatroe Sgnatur � Cer4fied Rep.No. Date �- ORONO Rob Stcx�ola LOCAL COPY 818 012 Name of Driller ? ID#52603 HE-01205-15(Rev.B/13)