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� , _ � _ _ . WELL LQCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUEWELL NO. County Name WELL AND BORING RECORD � 9� �g 8 i� Minnesota Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Ft. o� �v 23 a �, �,. �, GPS DRILLING METHOD Latitude degrees minutes seconds _ LOCATION: � i Cable Tool nven ��'�Dug Longitude _ degrees minutes seconds �'-j Auger �otary ��J Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � Ji7Y3 �t AVe OCOLIO �S.7C7Y DRILLING FLUID WELL HYDROFRACTURED? �='Yes � No Shop exact location of well in section grid with"X'�. Sketch map of well location. �tCRlite FROM ft.TO ft. Showing property lines, N . / roads and buildings USE Lj Monitoring ❑Heating/Cooling ; � ; ; ; � � � `t� ,,.`_� �Domestic [ ��Environ.Bore Hole ❑Industry/Commercial , . _J�,D — r�. __'_____'_" _'_`__ ___`_ *„ ,Noncommunity PWS =,�Irrigation rl Remedial �� Communiry PWS � �i_]Dewatering _ --'--- --',--- ---`-----t-- �.? .� ASING HOLE DIAM: �,l)"' C � � Drive Shoe? r_,i Yes �No .: W � ' E T �]Steel �J Threaded ��Welded � � , , �... - ,-- �- --'�— � —, . �Plastic �J '/I Mile '- '-`--- --'--- -''-- ---i-- 1 CASING DIAMETER WEIGHT i i S i ' .—'�"._. � in.to_ �� ft �so� Ibs.ffL Q in.ro -�Yt. �--1 Mile—� � �/� _ in.ro ft. _Ibs./R `�1 in.to �-�Yt. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. gM, �L� � OPEN HOLE s�<��l E� SCREEN__ Property owner's mailing address if differeN than well location address indicated above. Make_ . �_`� FROM ft. TO ft. � TYPe—��41___ Diam.— ------ -- - �� SIoUGauze_.__��1�_.. .__Length�___ ______. __ �_ Set between ft.and fL FITTINGS_ M - STATIC WATER LEVEL 3� ft.�below [,above land surface Date measured____Z�_ PUMPING LEVEL(below land surface) WELL OWNER'S NAME/COMPANY NAME � ��3 1�5 hr'pumping� C74J_. g.p.m. ft.after L HEAD COMPLETION �1= Well owner's mailing address if different than property owners address indicated above. _�Pitless adapter manufacturer �1I71��t�,r__..-_ fyloylel__ Casing Protection_ _ ----__ ��12 in.above grade 'At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATION Well grouted �Yes i_-�,No �f } Grout material �]Neat cement ��Bentonite ❑Concrete,�High Solids Bentonite from O � to._� . ft. � � 'yds �ags from� to��._ft.�t�81 f��y�s ��_'bags , GEOLOGICAL MATERIALS COLOR H MA ERIAL�F FROM TO from_ to._.__ ft. __._ :��,yds. ��_]bags , NEAREST KNOWN SOURCE OF CON7AMINATION tO f� ��w`L �� ` --J feet /'� direction � ' _ � '-"'t�pe 1 8S�ll Well disinfected upon completion � Yes i__j No - PUMP cl black eaf - - ��Not installed Date installed_ _ _ 11�� . t black �f Manufacturer's name ��L�r „ ------- --- ---- Model number___-�a� HP �'�Volts__ �� ;. C�8 )� f Length of drop pipe v, _ ft. Capacity _ ___._—— g.p.m. t r Type:� �.Submersible ,]LS.Turbine �r��'Reciprocating ��-'�.Jet IJ $� L ABAN ONED WELLS U ,�./ Does property have any not in use and not sealed well(s) ' l'Yes '7'�No . VARIANCE Was a variance granted from the MDH for this well? [',Yes � ,No TN# WELL CONTRACTOR CERTIFICATION � This well was drilied under my supervision and in accordance with Minnesota Rules,Chapter 4725. . The information contained in this report is true to the best of my knoeviedge. Use a second sheet.if needed �/ REMARKS,ELEVATION,SOURCE OF DATA,etc. � Stodols We11 Dri111n�Co�� IZIC�____2�7� __ Licensee Business Name . Lic.or Reg.No � �<�� - 2I--17-{)3 � - � f��_ Authorized Representative Signature � Date Cln�CtC ML)f�L�e 20-30-03 LOCAL COPY �(��Q Name o7�riuer �ate � v HE-01205-OS(Aev.5/02) IC 140-0020