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� r , �ECE11/�NESOTA DEPARTMENT OF HEALTH MIN AND BORIN�G NOwELL WELUBORING LOCATION ,. County Name MAY 2 9 WELL AND BORING RECORD -- 7 3 91� 7 �� 200�1�nnesota Stafutes,Chapter 103I � Township Name Township No. Range No. �tid�Yfyp� r tion WEWBORING DEPTH(completed) DATE WORK COMPLETED f 117 23 (3$J �R0��0 �ia 22$ n IZ-14-06 GPS DRILLING METHOD ,.- LOCATION: Latitude___ degrees minutes_.__ seconds _ �� ..Cable Tool l' nven �.Dug -� Congitude_._._ degrees_._ minutes__._ seconds � �Auger "�Rotary C 1 Jetted ` House Numbetrq,S�t,r.eet Name,City,and Zip C!o�d.e.�o.f.W�.e,l,l Location or Fire Number � �� ''A��J P�� v�'�� DRILLINGFLUID WELLHYDROFRACTURED? I._iYes o Show exact location of well/boring in section grid ith"X." Sketch map of well locatio . �Q� e From ft.To ft. Showing property lines, N roads,buildings, USE _ omestic CI Monitoring ❑Heating/Cooling and direction. �' �.Noncommunity PWS I I Environ.Bore Hole '-!Industry/Commercial --'--- --'-- -`- .' ; ; ; - ---'-- �-Community PWS "Irrigation „]Remedial --;--- --i--- --`-----'- _ - � I 1 Elevator ' .Dewatering CASING MATERIAL Drive Shoe? I�Yes No HOLE DIAM. a ; � � , W , , � ET + ; ; , ; ❑ hreaded C.Welded L l teel T lastic ❑ � Vz Mile -�--- --'- --�-- --'-- CASING �.. � \ Diameter Weight Specifications ; ;--S ; 1 � .'� �-1 Mile� � in.to ��v _ft. � Ibs./ft. _ � in.to � ft. _, in.to_..___ ft. Ibs./ft. �in.to�ft. � PROPERTY OWNER'S NAME/COMPANY NAME in.to___, ft. Ibs./ft. in.to ft. Vogu� Design � Realty Inc. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make � From ft.To ft. Zfi18 Cssco Point Rd sfs�rt�s�2 ; t�� C�fA1 Type ___ _]�'� Diam. :. WByZ$tss TJC'( S1J71 SIoUGauze e�'�'L+++�+ �p Lengt��1f�#�� � Set between L�__ft.and ZL.G) ft. FITTINGS G �J ��i1�I� STATI ATER LEVEL �� � ___._�-+� fL�Below '.��Above land surface Date measured ____._ PUMPING LEVEL(tielow land surface) WELL/BORING OWNER'S NAME/COMPANY NAME (� e} � _ �"" ___ft.after 4 hrs.pumping _g.p.m. WELL HEAD COMPLETION � � {�'� � �' � Weil/boring owner's mailing address if different than property owner's address indicated above. . itless Adapter Manufacturer J-y�V'-+�-�"�'^�""�'�10 0�l 'J Casing Protection_ _ '�!'�12 in.above grade � ��.-At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION � Well grouted? �Yes �. i No ,/ „� Grout materials . i Neat cement A'1"Bentonite f I Concrete !I Other �� From�To__ '�R _� :_'Yds. �ags � . From_.�To�ft. __�.,+..if �21lii 1 �. :Bags HARDNESS OF [�iTiL3C ilii GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO From_. To ft. �� 1 Yds. �. �.Bags NEAREST KNOWN SOURCE OF CONTAMINATION �.'ZC'3�7 �T$12.�917 �i.Z�i � �5 ��`�, feet •�'{`� —direction �-�. , ::%s.�'"_�9P� Well disintected upon completion? I Yes f 7 No _J}_� '� y..��,,.._� clay/gravel/sanci mediu�s 35 195 PUMP . �.Not installed Date installe /� �� "f� -- fi(� �(� g�y (�1(ii� I75 2�0 Manufacturer's name �s""`^�`�..�3"� 3 Model Number HP � /a Volts "�"'�� � G'�`-'Y �� Q ��" Lengih of drop pipe ��`v ft. Capacity g.p.m. ��^� Type:II�SSubmersible ��:��:L.S.Turbine ' �Reciprocating L 1 Jet �. ABANDONED WELLS Does property have any not in use and not sealed well(s)? ��Yes ��No VARIANCE Was a variance granted from the MDH for[his well? �I Yes No TN# WELL CONTRACTOR 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 of my knowledge. Use a second sheet,if needed. s REMARKS,ELEVATION,SOURCE OF DATA,etc. D�S�odc�la We11 _Dcillic�_Co�_. Iric. 1b91 Licensee Busines N e �� Lic.or Reg.No. ;� � � G � Aut ¢ed Representative Signature �� Date .1�IIt �t}�1�8 -- __ _— --- —. Name of Driller LOCAL COPY 7 3 g�� 7 HE-01205-09(Rev.9/O5) � IC 140-0020