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<br /> ; WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINN�bTA�i�I(7tltl�i L NO.
<br /> � County Name WELL AND BORING RECORD
<br /> Minnesota Statutes,Chapter f031 ,����
<br /> '� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
<br /> tt i,ITY F S? N
<br /> - GPS � � �
<br /> Latitude degrees minutes seconds DRILLING METHOD
<br /> ' LOCATION: ---
<br /> .= Longitude degrees minutes seconds ❑Cable Tool �]Driven � -�Dug
<br /> t ❑Auger �Rotary ��Jetted -
<br /> House Number,Street Name.City,and Zip Code of Well Location or Fire Number J
<br /> DRILLWG FLUID WELL HYDROFRACTURED? �,]Yes -1 No
<br /> Show exact location of well in section grid . Sketch map of well bcation. Aa�EC FROM ft.TO ft.
<br /> . `� ' Showing property lines, --
<br /> _ N � �'�, roads and buildings USE -�- �-. :
<br /> -- � � _Monitoring J Heating/Cooling
<br /> `� � � � � ' Domestic �Environ.Bore Hole ❑Industry/Commercial
<br /> � --'-- --' -`----`-
<br /> �,_ ; ; j j �� oncommunity PWS ❑Irrigation �J Remedial
<br /> �,� N ` •
<br /> I I I ; � I �Community PWS ❑Dewatering ❑
<br /> '--- ' - ---` `- :.
<br /> , � CASING HOLE DIAM. �
<br /> - w , e T �' � Drive Shoe� [�.]Yes �No �
<br /> �� -,---, ---�-- ;-- I `, ❑Steel r Threaded [Welded ��
<br /> � , , , , Mile ` -
<br /> ,h �- � ` - Plastic •
<br /> ------------ ------ --.-- 1 ,,,
<br /> '�� • �� CASING DIAMETER WEIGHT
<br /> S * e� 4 p A .
<br /> � in.to s�` ft. ���1 Ibs./ft. O in.to ���ft
<br /> i 1 Mile -�
<br /> � PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./fl. in.to ft.
<br /> St ructural IIAR'g� SCREEN OPEN HOLE
<br /> Proper?y owner's mailing address if different than well location address indicated above. Make p ��t FROM ft. TO ft.
<br /> I405 �1 Lilac Dr, a�ftt' G26 Type PLBC_._ Diam.
<br /> ' ��ld�n Valley, r71� 55�22 SIoUGauze ����__. Length�j_.,�.�___
<br /> Set between ft.and it. FITTINGS n M
<br /> STATIC WATER LEVEL
<br /> `-'� fL�elow ��]above land surface Date measured �1�2`�4
<br /> PUMPING LEVEL(below land surtace)
<br /> °� WELL OWNER'S NAME/COMPANY NAME j .
<br /> a 70 ft.after � hrs.pumping �S
<br /> g.p.m.
<br /> WELL HEAD COMPLETION y.,�
<br /> �. Well owner's mailing address if different than property owners address indicated above. itless adapter manufacturer �j,� --�t[ �.3,r. Model
<br /> � .Casing Protection -'��. 2 in.above grade
<br /> ��At-grade(Environmental Wells and Boring ONLY) � �
<br /> GROUTING INFORMATION
<br /> Well grouted �J Yes ❑No
<br /> Grout material �,_Neat cement ��Bentonite ;J Concrete�'High Solids Bentonite
<br /> from O to �Oft. � ` yds. bags
<br /> from 3� to �72ft. QStL1C$�;��ags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to fl. �
<br /> MATERIAL []yds. �. ;bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> �.'18y 3Te�,1�W $�f t Q j 6 ��1 � --feet ,�`"�,,,. direction _ T - �YPe
<br /> Well disinfected upon completion Yes ❑No �
<br /> clay gcay aoft 16 60 PUMP
<br /> / � _ �f
<br /> �Not installed Date installed ! � ' � �
<br /> sand �C'$�T $Q�t �j� i 1 O Manufacturer's name . �•�-..�.•�•�,.....-r�'�""'-'
<br /> Model number HP � �1 Volts .�'x�.��
<br /> rg $�l� 11� �70Len thofdro f
<br /> C�8y � Y 9 P P�Pe �;��L�'j ft. Capacity g.p.m.
<br /> 1 p Type:F � Submersible [:�LS.Turbine ❑Reciprocating ❑Jet ❑
<br /> ' watersand brorat� $�f�' y7� 1pO"ABANDONEDWELLS
<br /> Does property have any not in use and not sealed well(s) ❑Yes No
<br /> VARIANCE
<br /> Was a variance granted from the MDH br this well? ❑Yes No TN#
<br /> WELL CONTRACTOR CERTIFICATION .
<br /> - This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
<br /> The information contained in this report is true to the best of my knowledge. .
<br /> Use a second sheet,if needed !�
<br /> ? REMARKS,ELEVATION,SOUFCE OF DATA,eta !1(�n a7 t wifitta We I 1 D r i 11 i ng Ca., i QC Z �(��
<br /> Licensee Business Name Lic.or Reg.No.
<br /> �
<br /> /� __ .. : ,, ..� , �
<br /> l�:..:�"�� ._�a��� i;,/�
<br /> a e Date
<br /> Chuck Moare
<br /> Name of Driller
<br /> LOCAL COPY 7 � � � � �
<br /> HE�01205-08(fiev.5/02)
<br /> � IC 140-0020
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