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� MINNESOTA DEPARTMENT OF HEALTH M'N AEND BORIN��G NO. ELL 1NELL OR BORING LOCATION WELL AND BORING RECORD Counry Name P `� � �� " Nehrie in Minnesota Statutes,Cha ter 1037 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Vi.�IW �10 � ZV '/< '/. '/< lYV n� � GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds L�Cable Tool ❑Driven ❑Dug ❑Auger �Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � I��tS AV� OCOTIO 5535b DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section id with"X" Sketch map of well/boring location. ��te From ft.To ft. Showing property lines, - N roads,buildings,and direction. USE �Domestic ❑Monitoring ❑Heating/Cooling ' __;__ __i__ .__�_____;__ '`-- ❑Noncommunity PWS ❑Environ.Bore Hole []Industry/Commercial �+� ,�, ❑Community PWS ❑Irrigation ❑Remedial ' I I I I � � �' ' . �* --�--- —;--- ---�-- ---;-- � ❑Elevator �]Dewatering ❑ ,� w ; ; ; ; E t� � CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. � , . , T .., .�,. � ' --'---"-'-"" -""`-- ---'-- ' ' � ❑Steel ❑Threaded ❑Welded , , , , Mlle� �� , , , , �� '� Plastic . --,-----r-- ---�-----:- 1 , /"^� ° �T ��.,,)�. CASING ,. � � S � � Diameter Weight Specifications �, R '�(� s �—i na,ie—� y�F- � in.to 132 h ��9 Ibs./ft. � " in.to�"' ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. �in.to��. Je�'� AL"(� _in.to _ ___ft. Ibs./R. in.to ft. Property owner's mailing La�ddress if different than well location address indicated above. SCREEN OPEN HOLE � SS aWYe Make�� From ft. To ft. Type "4i"�"�+�$ �t Diam. /r t SIoUGauze •01 . Length 4� �' �i� Set between��_ _ft.and ��ft. FITTINGS � � STATIC WATER LEVEL Measured from � ft.�Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) _�,�_ ft.after ��hrs.pumping g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �Pitless/adapter manufacturer. ��-�"�--blodel �]Casing Protection �12 in.above grade ]At-grade(Environmental Well and Boring ONLY) GROUTING INFORM�ITJON Well grouted ��Yes U No Grout materials ❑Neat cement�Bentonite ❑Concrete ❑Other From_�To�ft. _�_ ❑Yds. �Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From__�To__1.,�,2_ft�$1"i7�.�Aids. ❑Bags MATERIAL From To ft. ❑Yds. ❑Bags e �f� O �� NEAREST KNOWN SOURCE OF CONTAMINATION - �Y 8�Y // .--- 1 (�.� feet �.� direction '-,.J-^'�''' • � ¢_��/�_y_ ��0� �� Well disinfected upon completion? es ❑No d CV\�iCD PUMP } % ❑Not installed Date installed �f ��yr J � , Manufacturer'sname �-•T'x—�`� �� J Model Number HP��L Volts ::�-�'G Lengih of drop pipe f �.,� ft. Capacily g.p.m. Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes pi No VARIANCE Was a variance granted from the MDH for this well? ❑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. REMARKS,ELEVATION,SOURCE OF DATA,etc. �1 �'CO1Lti3 �C�1 L�i��p ��• InC• ICT71 .�� Licensee Business Name Lic.or Reg.No. ,.f_ :, "�l i Representative re Certified Rep.No. Date LOCAL COPY 750659 `�` �°°� Name of Driller IC 140-0020 HE-01205-10(Rev.6/06)