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. � _ , - �, � . :-= �, � ; � � �.;.. � :�. � r , MINNESOTA UNIQUE WELL WELL OR BOFjWG LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. � County Name WELL AND BORING RECORD 7 g 19 8 3 � �p� Minnesota Statutes,Chapter 103I ' Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED .r OrOc�a 27.7 23 20 A�E S$ �Ty, Zf?� n �3"'22-12 GPS DRILLING METHOD : LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds ❑Cable Tool J Driven j�Auger �iotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number �Other i I4/3 � R� il�l, VLLA,p,;► �5�1 DRILLWG FLUID WEL�I'4YDROFRACTURED? ��,.I Yes j o Show exact location of well/boring in section grid th`X" Sketch map of well/boring location. ��(�1r From� ft.To ft. Showing property lines, N roads,buildings,and direction. USE L�omestic ❑Monitoring ❑Heating/Cooling ' __J___ ._j___ ___�_____i_ _J Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial _]Community PWS [J Irrigation ❑Remedial --'-- --;-- --`-----�-- ` _J Elevator ,r]Dewatering ❑ � . w ; ; ; ; E � �" `"' � CASING MATERIAL Drive Shoe? ❑Yes ,�No HOLE DIAM. --,--- --.--- --�-----.-- T . ❑Steel �_�Threaded ❑Welded � � � � Mile StiC [.].. 'h --,--- r --� --.- 1 �f'la ; ; ; CASING S � �. Diam�er �g� WeighL� Specifications � � �', �._y � i . 1 �1 Mile� � t¢}Ex' _ in.To____. ft. Ibs./ft. in.To�ft. PROPERTY OWNER'S NAME/COMPANY NAME � in.To____ ft. Ibs./ft. ,_ �in.To_ ft T� y�� in.To _ft. _ Ibs./ft. in.To ft i'AA � . � � OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN _j ��s Make �tisl�!$�7� From ft. To ft. � Type ___ Diam. j,�� __ SIoUGauze �� /'�� Length_____ ♦ '* Set between � ft.and_.GV�ft. FITTINGS_ i STATIC WATER LEVEL ap Measured from_ J{?_______ ft. Below �_j Above land surface Date measured��'� WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ` 17�/ ft.after____ 4 _____ __ 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___lnlit�ter Model y ❑Casing protection __ �72 in.above grade ❑At-grade ❑Well House �Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or olher) - Matenal_��rom�To_�ft � __�__ [ �Yds. �ags Matenal�,�_ �r�i��To�g�ft. ___ ��Yds. ❑Bags ` HARDNESS OF Matenal_ From_ ,_____To__ ft. ❑Yds. ❑Bags : GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION _� _ � � �� b.3.�:k �1� �✓ +� ��(.� feet � direction �'-�`s°,� �._,� �,...rype . Well disinfected�upon completion? �Yes ❑No :a�.W, ` ��'`" G� i3LVf�f! �}�t Z �� PUMP -' �Notinstalled Dateinstalled__ .__ ___�6�12__ �� C�8 �� `� �� Manufacturer's name ��e= � � � � Ai��l.� 95 1� Model Number HP�_��Volts Length of drop pipe �g ft Capacity g.p.m �e� �j� �j� �� ` Type:� ubmersible _LS.Turbine 0 Reciprocating ❑Jet ❑ s�� j' � ABANDONED WELLS Does property have any not in use and not sealed well(s)? J Yes �No VARIANCE Was a variance granted from the MDH tor this well? ❑Yes [�Jo TN# WELL CONTRACTOF 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 ot my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA..etc. Don Stvclola �k3.1 Drilling Co,. Inc. 2691 . Licensee Business Name -- - � Lic.or Reg.No. �..- ! , <-:�--�� IO-4-12 , _- -�-T— --------___ ; 3 tified Representative Signature Certified Rep.No. Date LOCAL COPY 7 919 8 3 � ��8�— — -- Name of Driller IC 140-0020 HE-01205-13(Rev.U/10) �