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� � � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELL AND BORING RECORD "7 ,, �` ��j,�j Minnesota Statutes,Chapter 103I ( � ��t``�.`='� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed ; Orr�o 117 23 05 ,' �a �i y, ,. , GPS DRILLWG METHOD LOCATION: Latitude degrees minutes seconds 3 Longitude degrees minutes seconds _'Cable Tool ❑Driven Dug --- � Auger �Rotary i_,Jetted House Number,Street Name,CiYy,and Zip Code of Well Location or Fire Number � �J � 325 Crestviev Av�, � SJJ�� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well in section grid with"X". Sketch map of well I ati �tVIUt� FROM ft.TO R. Showing proper line , roads and b Idin�s USE ` N � � 1 Monitorin Heating/Cooling I I I � \ �Domestic ❑Environ.Bore Hole ❑Industry/Commercial �� 9 �i �� j j j ; S 'i] rrigat � Remedial ��— �} ❑Noncommunity PW I ion 9 u � � � � ""- � ❑C nity P ��Dewaterin �- - -- -- ------ ----- -- j ommu WS J _ � L �3 w ; ; ; ` E T j ASWG Drive Shoe? �Yes `'�No OLE DIAM. � C H �•_ --;--- --�----�----,-- I � _ h.eaded i- elded �'.Steel ❑T � ��.W �; , , , , Mile ,� [�Plastic ❑ ; - --;-----'------�-----`- CASING DIAMETER WEIGHT �� S - 1 �� �—i htiie—� p�u �' � -�—in.to_��_ft. �� Ibs./ft. '' in.to__�ft. - in.to . .___,ft. _____ Ibs./ft. in.to�_ft. .',� PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs.fft. in.to ft. ��' ��t � SCREEN� OPEN HOLE 'i ' T �i Property owner's mailing address if different than well location address indicated above. Make_.`'��J^g�♦ FROM fL TO R. ri�; 1I4324 H�zriclert�ck Rd Type_ �tS1I11�$ S�tl Diam _ ��: l�a$�� !iN 55318 SlovGauze__ _T��n Lengt11�1 __ _ Set between ft.and ft. FITTINGS N � STATIC WATER LEVEL - �� ft. - below j ;above land surface Date measured �_�� PUMPING LEVEL(below land surface) WELL OWNER'S NAME/COMPANY NAME ft.after hrs.pumping g.p.m. - � WELL HEAD COMPLETION ,hj 9�� Well owner's mailing address if different than property owners address indicated above. �Pitless adapter manutacturer �}�.�'4��_�J�U�'��YvlodeL` �Casing Protection ��y[f2 in.above grade ,_At-grade(Environmental Wells and Boring ONLY) � GROUTING INFORMATION Well grouted 'I.�Yes ��No Grout material T_Neat cement ❑Bentonite [_�Concrete�High Solids Bentonite from__�_to��fl. __� I�I yds. �bags from_��to_}A�ft. ��#xc�. , �bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to fl. , .yds �]ba s MATERIAL 9 NEAREST KNOWN SOURCE OF CONTAMINATION C18v b� � 'JV �� feet f�� direction' -'.�R�'.,-x-.s..�...t+'»"'�pg � `�.� Well disinfected upon completion �- Yes [ �No " j�� f—:��..�...<;•n CLAy $CS� �I � � PUMP �Not installed Date ins�t.-a!l�le'd �y'� �./� Ci$VI� cyt'ffv i� "� �5 Manufacturer's name �--"`�"-"-^'Y��-'�"�`^' J o...�., / �� _ � Model number HP / Volts �rav�ellclsy �ay g�l t Q3 7V Length of drop pipe �..�i�� ft. Capacity g.p m. ,,,_r,� �ry /yt Type:. � ubmersible f_)LS.Turbine ❑Reciprocating ❑Jet ❑ -�. N$t�C.�7�iill �C�31 ��ZI 7L 1VJ 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 this well? r J Yes o 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 c► tL� �y,� l �/ �� REMARKS,ELEVATION,SOURCE OF DATA,etc. � .7C�OIS v�C�l .er611�1LI�j CO�r �• ��/Z Licensee Busines ame Lic.or Reg.No. �,-' ti�. �� s t rized Representati Signature Date Jirn Kohis LOCAL COPY j '} � Q F� 7 Nameo�Driller f r 0 ,.. O HE-01205-OB(Ree SI02) - IC 140-0020