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rt.:. ,� , ,__ . .., , _ ._ _ . . _. _ . . ....,.,:_ , _ � MINNESOTA UN/QUE WELL � OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. co� -,e WELL AND BORING CONSTRUCTION RECORD 81 H O O� �7�.��t�c�` Minnesota Siatutes,Chapter 103I ?rwnship Name Township No. Range No. Section No. Fraction WELL/BORWG DEPTH(completed) DATE WORK COMPLETED �- ,, I RO n 11-24-15 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD % Latitude Longitude ❑Cable Tool [�Driven � ❑Auger �Rotary � House Number,Street Name,City,and ZIP Code of Well Location ❑Other - DRILLING FLUID WELL HYDROFRACTURED? ❑Yes a Show exact location of well/ oring in section grid with"X:' Sketch map of welUbori loc ion. �tet' From ft.To ft. Showing pro erry;�nes, — N _ roads,buildings,an c�t[�Ltion. USE �Domestic ❑Monitoring ��Heating/Cooling = � � � � ) Noncommunity PWS ❑Environ.Bore Hole '^'�Industry/Commercial --�-----J------�-- ---•-- � h�� -�} ° +, � , , � ,� '''� ❑Community PWS ❑Irrigation [�Remedial 4 : _.�--- --�-----�-----:— ❑Elevator j]Dewatering [� ;.. w ' ; ; ; e T CASWG MATERIAL Drive Shoe? ❑Yes �No HOLE DIAM. ' ' ` ` I _S ❑Steel ❑Threaded ❑W Id d e e � ; ; ; ; nn�ie r� y v,� > Plastic --:--. , , , 1 � 7 ---;---s--:-- ---:- �. � � � � CASING � � � � Diameter Weight Specifications �-1 Mile� � ? � � in.To 1..�_ft. Ibs./ft. _ �in.To_�ft. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. V'�__in.Ta1Hd ft. � in.To ft. Ibs./ft. in.To ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE Make �� From ft. To ft. Type g�8;2[��$ ,,,�� Diam. - SIoUGauze �� Length��, �t Set between ft.and fl. FITTINGS STATIC WATER L V L Measured from 77 ft. Below ❑Above land surface Date measured � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ' �65 ft.aRer g 2 hrs.pumping �0 4 p m_ Well/boring owner's mailing address if different[han properry owner's address indicated above. WELLHEAD COMPLETION �Pitless/adapter manufacturer�t��t�r Model �Casing protection �12 in.above grade ❑At-grade ��Weli House (�Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material t�n.'��P From_�__To�_ft. � __�__ ❑Yds. �Bags �� ; Material�tu�_��__��To__�,��_ft. �Yds. �Bags HAFDNESS OF Matenal From To ft. ❑Yds. i�Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION $$(j� ��,j __feet CJ✓ direction -_ a. -� �--� _type Well disinfected upon completion? �Yes ❑No PUMP ❑Not installed Date installed _ �1"2 J�i J �.'I8 it Manufacturer's name Madel Number _ HP��_Volts�'� sar� Length of drop pipe Z26 _ft. Capacity g.p.m r.� Type�Submersible �'_,LS.Turbine [;Reciprocating ❑Jet ❑ S�IlU C H a ABANDONED WELLS �_3 Does property have any not in use and not sealed well(s)? �]Yes � �No �K-� = VARIANCE �y� Was a variance granted from the MDH for this well? ❑Yes No TN# FA1 `� 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. t-r�$V Use a sec et,il needed. EMARKS,ELEVATION,SOURCE OF DATA,etc. Ibn Stoc�ola �11 t)rf llin� co,. Inc. I691 Licensee Business Na e Lic.or Reg.No. ..`�� � � , � .-�� 12-17-15 ; ;^'�,' "s�`` ' - — � erti�fgd`R rese r e Si�r(ature Certified Rep.No. Date � _ LOCAL COPY 818 0 0 3 Name of Driller �b S��p�� ID#52603 HE01205-15(Rev.8/13) s