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TA <br /> E <br /> UE <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BORINGG NO.WELL <br /> County Name WELL AND BORING CONSTRUCTION RECORD 8 8 5 8 3 5. <br /> Minnesota Statutes,chapter 1031 . <br /> Township Name Township No. Range No. Section No. Fraction(sm.—r-lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> ft. <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> ❑Auger ❑Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. From ft.To ft. <br /> Showing property lines, <br /> N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling <br /> ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> ❑Community PWS ❑Dewatering ❑Remedial <br /> ---- -;--- ❑Elevator ❑ <br /> w E T CASING MATERIAL Drive Shoe? ❑Yes ❑No HOLE DIAM. <br /> ❑Steel ❑Threaded ElWelded <br /> '/Mile ❑Plastic ❑ <br /> 1 <br /> CASING <br /> • s . Diameter Weight Specifications <br /> H1 Mile I in.To ft. lbs./ft. in.To ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. bs./ft. n.To ft. <br /> in.To ft. lbs./ft. in.To ft. <br /> OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN <br /> Make From ft. To ft. <br /> Type Diam. <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL ft. ❑Below ❑Above land surface <br /> Date measured Dry hole ❑ Yes ❑No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after hrs.pumping 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 Model <br /> ❑Casing protection ❑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 From To ft. ❑Yds. ❑Bags <br /> Material From To ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR FROM TO <br /> MATERIAL Driven casing seal From To Bags <br /> One bag=94 lbs.cement <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> • <br /> Well is feet direction from type <br /> Well disinfected upon completion? ❑Yes ❑No <br /> PUMP <br /> ❑Not installed Date installed <br /> Manufacturer's name <br /> Model Number HP Volts <br /> - Length of drop pipe ft. Capacity g.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)? ❑Yes ❑No <br /> VARIANCE <br /> 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 /> I Use a second sheet,if needed. <br /> 1 REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> I <br /> Licensee Business Name Lic.or Reg.No. <br /> Certified Representative Signature Certified R Date ep.No. <br /> LOCAL COPY 8 8 5 8 3 5 Name of Driller <br /> ID#52603 <br />