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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 4 8 5 7 2 <br /> ,���,�� � Minnesota Statutes Chapter 103/ <br /> Township Name Tovmship No. Range No. Sectfon No. FracNon WELL DEPTH(completed) Date Work Completed <br /> f�rs�s.�o lI7 23 1C! �a�,�.�Ei. S�' ,�. � 1:�7 � 9f 14/I�tU <br /> House Number,Street Name.Ciry,end Zip Code of Well Location or Fire Number DRILLING METHOD <br /> i?SO Axbo� S�r��t C s��l �3� ❑ CableTool ❑ Driven ❑ Dug <br /> s � � ❑Auger �I Rotary ❑Jetted <br /> Show exact locatlon of well in section grid with°X°. Sketch map of well location. ❑ <br /> Showing property tlnes, <br /> roads and bwldings. DRILLING FLUID WELL HYDROFRACTURED7 ❑YES I�NO <br /> N ,t� (".� <br /> i i i ,'� 4�;1,++.,. - W$�CT FHOM (t.to ft. <br /> -i -�- -i- -i <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> � � � � � f6 Domestic ❑ Community PWS ❑ IndusVy/Commercial <br /> -�- -�- -�- -�- r O Irtigatlon <br /> 1,�'�'. � ❑ Noncommunily PWS ❑ Remedlal <br /> yy � � � � E Y� ❑ Environ.Bare Hale ❑ Dewatering ❑ <br /> � � � , T �,f�w <br /> i i i i ��� CASING Drive Shoe1 ❑Yes �No HOLE DIAM. <br /> i- -�- -i- -i- ❑ Steel ❑Thread� ❑Welded <br /> S <br /> 1 � �.�d�_..,� .�P��� � ���� <br /> ���� CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME +�! in,to �g� tt. IbsJR. �� in.to�SA tt. <br /> �"n �. Fc71'��.@ In.to ft. IbsJfL �In.to�>�R <br /> Properry owners mailing address ff different than well location address indicated above. in.to ft. � Ibs./tt. _�,to_ft. <br /> 125t� Aiccbor S'Cr�Lt SCREEN OPEN HOLE <br /> Gr�st�l �a.y, '�i 55323 M�8 �a��a from n►a rc. <br /> Type g�t+ Diam. �tt <br /> SIoVGauze_i.�' Length �� <br /> Set between �7�_ft.and�_ft. FITTINGS: ����,C�{@p' <br /> STATIC WATER LEVEL } <br /> WELL OWNER'S NAME � ft.�below �above land surtace Date measured�/1 I_�___�____^f�`I� <br /> PUMPING LEVEL(below land suAace) <br /> Well ownePs mailing address fl different than property ovmer's address indicated above. (t. after hrs.pumping �Q a.p.m. <br /> WELL HEAD COMPLETION <br /> W�Pl�ess adapter manufacturer �9ntr�_Model �f� <br /> ❑ Casing Protection �Q,12 In.above grade <br /> ❑At-grade(Environmental Wetls and Borings ONLI� <br /> GROUTING INFORMATION <br /> Wetl groutedl �,Yes ❑ No <br /> HARDNESS OF Grout Material ❑ Neat ceme BentonRe ❑ Concrete ❑ Hi h Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �m �j �`to (�S n. � ❑ yds. 6� bags <br /> from to ft. ❑ yds. ❑ bags <br /> �'la�i ���-�� � �5 from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> (�'i$!7 �i'ra�'g �� �.�j� feet direction �type _ <br /> Well disinfected upon completion? �Yes ❑ No <br /> GTr^SV�E'�/G�.'�.�,� G'gc4� �.VQ 17�D PUMP <br /> ❑ Notinstalled Datemstalled �1�E}��� <br /> ��'���1' ���� �'�� �'97 ManufactureYs name ��tT7PrB <br /> Modal number HP Volts <br /> Length of drop pipe $� ft. Capaciry =2 a.p.m. <br /> Type: Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)T ❑Yes �No <br /> VARIANCE <br /> Was a variance granted from the MDH for[his well? ❑ Yes No TN# <br /> 4 <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 Intormation contained in this report is true to the best of my knowledge. <br /> Stteven:� DriZiin� & Env. Se�rice�, I�.e. 86654 <br /> � Ucensee Busll�ess Name Lic.or Reg.No. <br /> � #� -� s, ��'ti, i4y ,'�m�3������ <br /> t �=t; <br /> Authorized RepieSentative Signatu e ' Date <br /> I�3i2la�' �Q��S+9L3 ����Fd�� � <br /> 6 4 8 5 7 2 Name o/Dnller Date <br /> LOCAL COPY HE-01205-07(Rev.2/99) <br />