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WELL LGM4 MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Nam WELL AND BORING RECORD 580432 <br /> ` z Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> t2rmt 01 11-/ 23 04 7-22-9E <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> z.:643 `l'I1C.iY.ougi1i)X'E'...[1 Dili_ 6ronc, rPtl ` !)31510 ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger $1 Rotary ❑ Jetted <br /> Show exact location of well in se grid with"X'. Sketch map of-well location. ❑ <br /> .§jpwirf j'property lines, <br /> „^,.•—��"' ads and buildings. DRILLING FLUID <br /> uta v� E D walle <br /> I I I I <br /> XWf USE ❑ Monitoring ❑ Heating/Cooling <br /> ®;Domestic ❑ Community PWS ❑ Industry/Commercial <br /> ❑ Irrigation ❑ NoncommunityPWS <br /> w E El Test Well ❑ Remedial <br /> I I I I ❑ Dewatering ❑ <br /> r r ,/ZM1e CASING Drive Shoe? ElYes ❑ No HOLE DIAM. <br /> 1 <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> O-Plastic ❑ <br /> s <br /> 1 Mile <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 19 SDMZ.�1 t -V8 <br /> 7 bny Esi den Cki CJc ny n.to ft. lbs./ft. _ _�t. <br /> in.to ft. lbs./ft. Irk to ;1�, <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. _in.to ft. <br /> 41 G-u berkshdre T.,ane SCREEN OPEN HOLE <br /> Pl � Mn. 446 Make jC111r1:;0,21 from ft.to ft. <br /> vr� i" a <br /> yiT 3U Type S+--a i Diam. <br /> Slot/Gauze t r t Length _ v <br /> Set between 6 ft.and 2f ft. FITTINGS: } t —6 <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME 11! ft. ❑jaelow, ❑ above land surface Date measured —L(— <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. t�.J ft. after 1 hrs.pumping ! 9-p M. <br /> WELL HEAD COMPLETION <br /> Pitless adapter manufacturer &,,;!T er Model <br /> ❑ Casing Protection 1 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? El-?Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement Ell <br /> s¢entonite El Concrete El High Solids Bentonite <br /> MATERIAL from 0 to =il ft. E ❑ yds.N bags <br /> Bl <br /> ad <br /> § from to ft. ❑ yds. ❑ bags <br /> Bla <br /> Clay from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINN <br /> ATIO / <br /> Clay Yell `W 5, z['t /�(5�) 1 feet er'S'"(�+.J 1J direction 'S�—type <br /> Well disinfected upon completion? [ .Yes ❑ No G <br /> Clay Grey S 20 SS PUMP <br /> ❑ Not installed Date`1,-nstal d <br /> r S : t• Manufacturer's name "'' CLGray;el htlii S t <br /> Model number 181,S15 4 1 t.L HP 11 Volts 2_340 <br /> Length of drop pipe 1 l` r ft. Capacity 1 g.p.m. <br /> Chy y ift 1 4" t Pressure Tank Capacity `25T' X- <br /> Length <br /> Type: C1-.Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes LI Allo <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes El-No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> DON V&LL EVULLING CO., 1W. 2?1 <br /> Licensee Business ame �Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> k're,6. IAA iby j-21.-9£ <br /> 5 $ 4 3 2 Name of Driller Date <br /> n0A1 00PY <br /> HE-01205-05(Rev.1/95) <br />