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_ _ ,s r,..,..�„ � MINNESOTA UNIQUE WELL WELL OR BURING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name � WELL AND BORING RECORD � � � 5 �2 Minnesota Statutes,Chapter 103/ � Township Name Township No. Range No. Section No. �' Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED � n. GPS Latitude degrees minutes seconds DRILLING METHOD LOCATION: --- r�CableTool [�Driven ,Dug Lon itude de rees minutes seconds � � - 9 — 9 ` !Auger �Rotary _�.Jetted House Number,Sheet Name,City,and Zip Code of Well Location or Fire Number '� DRILLWG FLUID WELL HYDROFRACTURED? �]Yes f,�No Show exact location of well/boring in section rid with"X` Sketch map of well/boring lo tion. �t��te From_ ft.To __ft. Showing property ines. N roads,buildings,and dir tion. USE �Domestic �_ ,Monitoring `_'Heating/Cooling I ; ' � ,_ � _� , �(,J [J Noncommunity PWS , �.Environ.Bore Hole [�Industry/Commercial �� '�' :.�/',�,� ��_ -,� !.�Community PWS , .Irrigation I�Remedial : � � __ __ __ __-- � ']Elevator �� ,Dewatering !1 � w ; ; ; .L e A��" CASWG MATERIAL Drive Shoe? ; �Yes �f No HOLE DIAM. - -----,--- --�-----:- T - �S - - �� ,...� , . teel I�Threaded ��Welded �i --�--- --�--- ---�-----�-- ile ,/z M ; _ 1 l � ,�Plastic I i �i,-_ CASING S ' . Diameter Weight Specitications �---1 Mile—� � in.to i� fl. Z Ibs./ft �in.to�.ft. � �p PROPERTY OWNER'S NAME/COMPANY NAME in.to _ _ft. IbsJft. �in.t�._�V ft. �� in.to _ _ _ft. IbsJft. in.to tt. OPEN HOLE Property owner's mailing address if differeM than well loca�ion address indicated above. SCREE T. 1.�/�� ',�� A� 7'� Make •+�� . � __ . __ From ft. To ft. � ��ll� M4�T 554�i7 TYPe a�afnless $t� . Diam.__.. .. � SIoUGauze _ �� __. Length��,�.�1 ��u'^� Set between_ _ _ft.and ft. FITTWGS_ f � STATIC WATER LEVEL Measured trom t * ��%•�- � � +`�"�'� ft.'�{�3elow �_�Above land surface Date measured �l� iZ � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) _ ��` ft.after �_ hrs.pumping Jl g.p.m. Well/boring owner's mailing address if different than properry owner's address indicated above. WELLHEAD COMPLETION �{ ; f�j Pitless/adapter manufacturer_�'++te�ater Model ,�Casing Protection _ __ __ � __ �12 in.above grade � ��.At-grade(Environmental Well and Boring ONLY) � GROUTING INFORMATION � Wel�� 'N° � � � � � Gro�ry� erial�Rli�N@eJr�qen�Bentonit�oncrete Other i!S C 1 Lili � From To ft L,Yds , _�Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft L.i Yds. i Bags MATERIAL From To ft. f_]Yds. i. I Bags . NEAREST KNOWN SOURCE OF CONTAMINATION � �'�' -� feet '+� _direction �.i�.., -+-�C..+ type Well disinfected upon completion? '',�Yes � ,No PUMP . r-�Not installed Date installed_ ___ 7�'L,Tl1 7 Manufacturer's name �er __ Model Number HP � Valts �� Length of drop pipe �� ft. Capacity �� g.p.m. Type,:�Submersible L �LS.Turbine �Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? �]Yes No VARIANCE Was a variance granted from the MDH tor this well? I,Yes No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chap�er 4725. The information contained in this report is hue to the best of my knowledge. Use a second sheet,if needed. � REMARKS,ELEVATION,SOURCE OF DATA,etc. �DOR2 ��OdQ�B �1� �.I�.��g CO.� �tlC. �� Licensee Business Name . Lic.or Reg.No. � _ J� '-ia�� C7—��-- i ��r! *" rtified Representative Signature �� Certified Rep.No. Date .��9 �l�t�S LOCAL COPY 7 8 3 5 0 2 - - ---- - Name of Driller HE-01205-12(Rev.i2/08) IC 140-0020