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� r � � MINNESOTA UNIQUE WELL <br /> �E!L:,�l30RING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORD .� � �6� � <br /> Minnesota Statutes,Chapter f031 <br /> � in <br /> Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> I27 23 07 �� �� �� 186 h 5-25-47 <br /> GPS DRILLING METHOD <br /> LOCAI'ION: Latitude degrees __ minutes seconds <br /> � Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug <br /> �Auger �Rotary ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire N mber C _ <br /> A A••ab 5T'',�/i ' DRILLING FLUID WELL HYDROFRACTURED? ❑Yes � No <br /> VL .iv-r <br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring localion. �BCet" From ft.To ft. <br />' Shov�itte property lines, <br /> N „ '''' -�-._,.�,,�,,,,�, buildr]�C„pad��irvction. USE �Domestic ❑Moniroring ❑Heating/Cooling <br /> __.___ __1__ ___L__ ___:__ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial �� <br /> ❑Community PWS ❑Irrigation ��Remedial <br /> --'-----.------F----`-- I ❑Elevator ❑Dewatering [-]-- ,- <br /> w ; ; ; ; E T CASING MATERIAL Drive Shoe? ❑Yes �No HOLE DIAM. <br /> i <br /> � --;---�-----%'---"�-- ... <br /> I ❑Steel ❑Threaded ❑Welded <br /> � ; ; ; ; 1M,�a st�� <br /> , , ---•- �Pla n : <br /> --;----;------;- ; ' CASING <br /> g • �y�, Diameter Weight Specifications <br /> �-7 Mile� �7'a �__in.to 17R ft. z.ai IbsJft. a�'� [ l//d to�ft. <br /> 1 Q� <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.t��+ft. <br /> in.to ft. Ibs./ft. in.to fl. <br /> Property owner's mailing address if different than well location address indicated above. , <br /> SCREEN 7�,t.._�,�..., aPEN HOLE <br /> ��. Make From ft. To ft. <br /> � g'B $�e Type Diam. <br /> SIoUGauze • * Length 4 f � /i� <br /> Set between�ft.and 1 � ft. FITTINGS <br /> �� STATIC WATER LEVEL <br /> Measured from <br /> 75 ft�Below ❑Above land surface Date measured � <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 170 ft.after 1�S hrs.pumping �1 g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated a ove. WELLHEAD COMPLETION ��jf. � <br /> Pitless/adapter manufacturer Mlll`�gt�r Model <br /> ❑Casing Protection ____ �12 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted �Yes ❑No <br /> Grout materials ❑Neat cement Bentonite ,/�i/C�oncrete ❑Other <br /> From � To_ 1�pN ft. 6w�5� ❑Yds. �Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FRO TO FromilA,�7 To I�V fl. ��iL1 ���. ❑Bags <br /> MATERIAL <br /> From To ft. ❑Yds. ❑Bags <br /> ' NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ^ / 4�..�:..,.. <br /> � �f t � 2� _ _ �'��.-� feet /V direction �����"�'� -^; " ,•,^type <br /> Well disinfected upon completion? Yes ❑No ,/!!)-f- ,�,�.,_ T',;;y_,c�,J�-. <br /> � $3 PUMP <br /> ❑Not installed Date installed �G7�/l <br /> �a �� Manufacturer's name e t.s..� <br /> �G[I�Cr�-��-- <br /> Model Number HP��4_Volts <br /> � �� ' ��� Length of drop pipe 105 ft. Capaciry g.p.m. <br /> £ �� �� Type:�Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ <br /> I ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes �No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? Yes C No TN# �� <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,il needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. �� S`���,18 �G�� �/L�llin� W s� i�.'a 1691 <br /> ..�<� <br /> Licensee Business Name Lic.or Reg.No. <br /> _`---; ✓ ti-ZQ-t�� <br /> erti ied Representative S' ature Certified Rep.No. Date <br /> LOCAL COPY <br /> 7 �0627 � �re <br /> Name of Driller <br /> IC 140-0020 � HE-01205-10(Rev.6/O6) <br />