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� T� , WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. c��Name WELL AND BORING RECORD 6 g�,��1 �iq Minnesota Statufes Chapter 1031 �.. Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Ococ�o I37 23 07 " ,, ,, , GPS DRILLING METHOD LOCATION: Latitude degrees minutes . seconds _ . r Cable 7001 U Driven Dug Longitude degrees minutes seconds ,�,�r -�� [,Auger �_�rtotary __Jetted House pNu/m�be/r+,.S,treet Name,City,and Znip,C.o,�de of Well Loca�tio�rn� or Fire Number �; / I1W �Xi� CC�� Vi{AR7 SSJV'F DRILLING FLUID WELL HYDROFRACTURED? ❑Yes i o Shop exact location of well in section grid wiih"X". Sketch map of well iocation. ��er FROM ft.TO ft. Showing property lines, N No cosmmunit pyys I`Monitoring ❑Heating/Cooling 1 , ' f roads and buildings USE [] y �,J Environ.Bore Hole i_;Indus�ry/Commercial --'-- —'-- ---`-- ---F- '� �Irrigation ❑Remedial ❑Community PWS �'��Dewatering ❑ --'"-"'-"-'--`-----`-- ASING OLE DIAM � W ; ; ; ; E� �� - - � � Drive Shoe� C Yes � : o � � � � ' \`� � Threaded ❑ elded --�-----�-----�-----%— �.�Steel _ . 'h Mile �j�; 18S1iC _ ""'""---'--- --'--�"-`-- � . ��,. CASWG DIAMETER WEIGHT S , e� p ' f � in.to��___fl. `�O� Ibs./ft. v in.to L�t. �1 Mile—� ��:..,` T 2L7Q in.to ft. Ibs./ft. 4 in.to_i}t. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in,to fl. � `' �S SCREEN OPEN HOLE Property owner's mailing addrescs if differert than well location address indicated above. Make__�_. _ . -- FROM ft. TO ft. 221 F i�cile r7t Type �A'�1'1�P�RR St; __ _ Diam ______ .Stlll�ter� �iN 55082 SbUGauze_ _ �� ____— — —_ Length__.._�1�,_�! Set between ft.and it. FITfINGS_ w STATIC WATER LEVEL 1� ft below �r�above land surface Date measured 11�3 PUMPING LEVEL(be ow land surface) - WELL OWNER'S NAME/COMPANY NAME l�g � 3 hrs.pumping g.p.m. ft.after �0 ------ -- -- - � WF�L HEAD COMPLETION �itewatec � Well owner's mailing address if different than property owners address indicated above. ��Pitless adapter manufacturer _____ �I_ ` -- _. � 1 Casing Protection .._ _____ 12 in.above grade ��At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATION Well grouted Yes �No ,�/ Grout material �Neat cemem �__Bento'n�it(e��_J Concrete;/�High Solids Bentonite from O to �+�+ ft. �/.,��* r�- 'I yds. y�,bags from � _to_ ��.,ft��R.L l�._�ls./�__J bags : GEOLOGICAL MATEFIALS COLOR HARDNESS OF FROM TO from _to_______ft '__'�,yda �_ I bags MATERIAL NEAREST KNOWN SOURCE OF CONTAMINATIO C1aV 11� �ft Q 18 -- '�" _teet _._ �� direction _`--"�'''ti�•--`"-��4type l Well disinfected upon completion Yes ❑No C� Csy BOlt IS �JIJ PUMP �.Not installed Date installed 1 s_�� .�j�JC�ay �$y �ft 17V ;W Manufacturer's name _��____ _________ Model number ._HP_ _�Volts__ ._ �..'lay� � r8� �i�il ��41 GJLJ Length of drop pipe 14!____ ft. Capacity ________._g.p.m. rq� L� Type: Submersible []LS.Turbine ❑Reciprocating ❑Jet J � L�� SOlC Z!l! ZW �AB DONED WELLS Does property have any not in use and not sealed well(s) �'��Yes � . o VARIANCE Was a variance granted from the MDH for this well? r�'�.Yes No TN# WELL CONTRACTOR CERTIRCATION This well was drilled under my supervision and in accordance with Minnesota Rules.Chapter 4725. The information contained in[his report is true to the best of my knowledge. Use a second sheet,if needed j�� s T REMARKS,ELEVATION,SOURCE OF DATA,etc. l./Vll .7todola Well Dcilling Co�: 1�• 27172 —_ -__. _--- - — ..—_. --� - Licensee �sin Name Lic.or Reg.No. � i` .,�.�.-_. . , � �—^ � �./�,�_ � - - 12-15-0� ; Aut orized Representative Signatur�' Date (�ck Pioo� 11-5�-U3 - - -- - -__ __ _ — -- -- _ LOCAL COPY 6�6 4 61 Name ol Drller Date HE-01205-08(Rev.5/02) IC 140-0020 �