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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. �. Count`Name -_� ��rj WELL AND BORING RECORD 5 � 0 5 71 � Minnesota Statutes Chapter f03/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed R. (iI:tTIl� � � i .l� l.�, 1� �i ° v. v. �i. House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRiLLING METHOD ,''�i'?�" t.::l'tRi:l_y'�57.t�e �Z�].V�,' {h�. �.'r��ili�'� F�jl, ❑ CableTool ❑ Driven ❑ Dug ❑ Auger f�Rotary ❑ Jetted Show exact location of well in section grid with"X". �r� - Sketch map of well location. ❑ - J��7 Showing property lines, . V roads and buildings. DRILLING FLUID � N �V ��.:1t.(.:ii�.L_G _i i i i_ 1}�V i _i' _i_ _ �_ USE ❑ Monitoring ❑ Heating/Cooling � i i i � � CXDomestic ❑ Communiry PWS ❑ Indust /Commercial i -� i i ❑ Irrigation ❑ Noncommunit PWS ry w E � Test Well Y ❑ Remedial i � � i ❑ Dewatering ❑ i i i r � CASING Drive Shce? ❑ Ves [};No HOLE DIAM. '/2 Mae _i_ _ i_ _i_ _�_ � ❑ Steel ❑ Threaded ❑ Welded � i i i dSPtastic ❑ s �.-,M��a-� CuUN,j!�� /'� �/.� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME �1 Lf � in.to �=�� n. � •� Ibs.ttt. 7 i�{.�Z .�. `k�!�rl� �1L�E..''Zl CC)I::TJct27�� in.to ft. Ibs.ttt. �i�.)6�N !# Property owner's mailing address if different than well location address indicated above. in.to tt. Ibs./tt. in.to ft. �a ��JI: BG3^1C�i�llX� Lc2.T�lf:' SCREEN OPENHOLE I I�ISIC�LI C.�'1� �i11. �J`-`'r�3 i) Make �" J� n`��'� from ft.to ft. 7yPe �`�c��11 �a'�:: wl�E��1 Diam. •�� SIoVGauze ��:�F�}I i Length � � ; '�---7� Set between � �� ft.and 1�+� ft. Fll'TING�5�� •�'� STATI��y/�FtiH LEVEL C. WELL OWNER'S NAME + i tt. 6�tielow ❑ above�and surface Date measured "—��'�= PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. � �� ft. after r • �� hrs.pumping S�� c�7.I� g.p.m. WELL HEAD COMPLETION C'�Pitlessadaptermanufacturer �Y�ilt,..,�°Wi:�P�Model ❑ Casing Protection �i1 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? j�Yes ❑ No HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete �;}ligh Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �, from to -'{'R. ❑ yds.� bags �' `i (`1- � c� � + ' � from ro ft. � yds. ❑ bags il(.i.t..- rZ 3E.�ZC.i �'? �� L.1+ from to ft. ❑ yds. ❑ bags Ci.. t (� . NEAREST KNOWN SOURCE OF CONTA,M`INATION �! e�^� ,,1�.1 l.Y �,1rE�1 �JI @� :? �;C,� � G{:i � �t,'�-' feet fVClFt• ! F+ direction �~"'��t� -f� tYPe � Well disinfected upon completion? C�Yes ❑ No L�.:i� Cir:1?rE�. �5�'G.til"t ;i �S�i ' ry4t c PUMP ❑ Not installed Date installed �� �c�I1C; �'.C�irS� �Z�f�tiT1 � �r ii y �(.'t� S Manufacturer's name K('.C; a1 c3(:K�l:. Model number � 5(;j,��(k j HP��Volts ��_ Length of drop pipe 9 '7 t ft. Capacity �r, g.p.m. �'jrf'T • �r? Pressure Tank Capacity �G�l.i ��2r'sl+t�?:.C�71 Type: �Submersible ❑ LS.Turbine ❑ Reciprocating � Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes C�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes ❑ Nb WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. 7he information contained in this report is irue to the best o(my knowledge. L�C`�: :,'?°CL'�:I:f: ;�Ik.i�L DRILLI�JG C:t�, , INC. L�cens�e Busine Name . r Lic.or Reg.No. i�� I L / r, ff� �' .�r' Ji' i� ��,�,'�"'�-, �"�{ �—L'� rM�-:; �� . I/S� , --�j 'Authorized Representafiv'e Signature - Date LIiL<:r: �+ic}('-Y'c? .;—��—�l n 7 Name ol Oriller Date ,.,._, ..„, , . � � �s a� 1 � HE-01205-05(Rev.1/95)