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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD 6 3 <br /> Minnesota Statutes,chapter 1031 <br /> Township Narfile Township No. Range No. Section No. Fraction(sm.--.lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> j, ft. <br /> "n r n ,,..it, -ry/4 .N, r/ ? J Z <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool [f Driven ❑Dual Rotary <br /> ❑Auger in Rotary ❑I Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes 10 No <br /> Show exact location of well/boring in section grst with"X.''' Sketch map of well/boring location, t <br /> Showing property lines, n © t <br /> e. From ft.To ft. <br /> N roads,buildings,and direction. USE in Domestic ❑Monitoring ❑Heating/Cooling <br /> I 1 1 I - <br /> J__-S___L I .... - -._-.. _-:_..- _- ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> I <br /> ❑Community PWS ❑Dewatering ❑Remedial <br /> -�---+- -- ---I-- , El Elevator ❑ <br /> 1 I F 1 <br /> w I I I I E CASING MATERIAL Drive Shoe? 7 Yes ❑No HOLE DIAM. <br /> -,---T- --r 0 Steel ❑Threaded ❑Welded <br /> 1 1 I 1 <br /> V Mile <br /> I I I I El Plastic El-----7- --;1*---I-1 CASING <br /> ' Diameter Weight Specifications <br /> I 1 Mile in,To ft. lbs,/ft. in.To ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME <br /> in.To ft. lbs./ft. i .Ta` ft. <br /> t o 31'1 ca, n 1 e 1 r i k s s o n in.To ft. lbs,/ft. in.To ft. <br /> SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. . <br /> Make From -. ft. To lll' ft. <br /> Type Diam. <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL ?",„ ft. Q Below ❑Above land surface <br /> r� <br /> Date measured r) C 2 2 2 Dry hole ❑Yes `'No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after 2 hrs.pumping 4 0 g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> 'Pitless/adapter manufacturer wh i t e Wa.t e r Model <br /> ❑Casing protection 0 12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material cut t i n L From To ft. ❑Yds, ❑Bags <br /> Material Bent O n 1-`'From • To ft. ❑Yds. MBags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> Driven casing seal From To Bags One bag=94 lbs.cement <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> r <br /> Well is feet direction from septic type <br /> 7 / Well disinfected upon completion? N Yes ❑No <br /> r 1a..y San r ,9 f . PUMP <br /> ❑Not installed Date installed C /2 )/`�2 <br /> " <br /> Sand/Clay ray' S 2 14 fer <br /> Manufacturer's name <br /> r j ,. Model Number HP 1 • 5 VoltsV 3 0 <br /> Length of drop pipe ft. Capacity 20 g.p.m. <br /> Sandy/Clay Gray S 158 19 a Type:❑`Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Gravel ,r a 'Pik 5 192 1 Q 9 Does property have any not in use and not sealed well(s)? ❑Yes El No <br /> 7 '1 VARIANCE <br /> o C k 105 70 r Was a variance granted from the MDH for 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,SOURCE OF DATA,etc. <br /> Don Stodola Well rillire Co <br /> Licensee Business Name Lic.or Reg.No. <br /> ----I /:,/ -• -7/,. - - .- <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY 8 6 6 J 3 <br /> Name of Driller <br /> iD#52603 HE-01205-18(Rev.3/19) <br />