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. . . . . . _ � . . . . f MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUE WELL , ., WELL C?r�BORING LOCATION AND BOR/NG NO. County Name � WELL AND BORING RECORD ��@p� Minnesota Statutes,Chapter 1031 � � ��}� � Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Oraio 117 23 Q2 ,� ,� ,� „. GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds ',�Cable Tool �Driven ❑Dug ❑Auger �]Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number j� 1Z� DiCR�� VLOEIO SS391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. �tW ilte From ft.To ft. Showing property lines, N _ ��roads,buildings,a di ction. USE Domestic Monitorin � '�( ❑ g ❑Heating/Cooling __J_____1__ ___t__.__:_� ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial �� ' ' ' ' �� ❑Community PWS ❑Irrigation ❑Remedial .� --'----,--- ---`—---'-- �� rl�Elevator ❑Dewatering ❑ W ; ; ; ; E T CASING MATERIAL Drive Shoe? ❑Yes �No HOLE DIAM. _ --;--- --�--- ---�-----<— � — ,. I (�Steel I;!Threaded ❑Welded �. � � � � Mile , � h �Plastic L, '�� - ------------ --.-- ---:-- 1 I I ' ' CASING S .: Diameter Wei htM Specifications �7 Miie—� � in.to �� ft ��Ul Ibs./ft. $'S� "�in.to�ft. � PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. _Ibs./ft. in.to ft. �ert Miller in to ft. Ibs./ft. in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE � �$ $� Make From . To ft. Type $� I1 es� �t Diam. SIoUGauze •Vl� Length� '* �f . Sef between I�I ft.and�� ft. FITTWGS�p p STATIC WATER LEVEL pp Measured from� O4 ft. Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)q I� ft.after_ ` hrs.pumping 4S g.p.m. Well/boring owners mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �t�ter I�Pitless/adapter manufacturer Model ❑Casing Protection �12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted f�Yes ',]Na Grout materials ❑Neat cement �Benronite ;]Concrete ❑Other ' From_Q__To_�__ft �_ ❑Yds. �Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From�To�'�_ft. �1❑��j Bags , MATERIAL From To ft. ❑Yds. ❑Bags NEAREST KNOWN SOURCE OF CONTAMINATION fi Il/sand br�l �� j -� _teet �� direction '_�.�C.� : ��---ry�e Well disinfected upon completion? Yes ❑No j._>"` ,d.. � �ia9 g=ay �ofc 3 i18 pUMP $ C�Bv/�� Qr$� �C� �� CO ❑Not installed Date installed ��7___ J O� 1 '� Sch�efer Manufacturer's name ,��1'�C,�e7 �� !t 1 C/� 1 p1 Model Number HP L�5 Volts i321xR1 1 1 �)lJ 101 Length of drop pipe 126 ft. Capaciry g.p.m. Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABA ONED 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? ❑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,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. RECEIVED D°" st°d°la w�ll n`i�.li`� �°., r�. 169I Licensee Business Name , Lic.or Reg.No. QEC 31 2007 " - f 6--2o-0� : i e resentative Signature Cer rfied Rep.No. Date LOCAL COPY 7 5 0 617 � �� — -------- -- Name of Driller IC 140-0020 HE-01205-10(Rev.6/06)