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MINNESOTA UNIQUE WELL <br /> WELL}OR�B�G LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO <br /> County Name WELL AND BORING RECORD 7 7 0 0� 4 <br /> Minnesota Statutes,Chapter 1037 <br /> in <br /> Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> OS 2� S� NB �� 2Q3 " 2-2D-Q9 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds ��Cable Tool ���r!Driven ���!Dug <br /> �J Auger '�id'Rotary �J Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number � T� <br /> DRILLING FLUID WELL HYDROFRACTURED? ��Yes �'�No <br /> �l.°T!t{!t!�t@ �. <br /> Show exact location of welUboring in section grid with"X:' Sketch map of well/boring I cati� . From ft.To R. <br /> Showing proper IiYies, <br /> N '" roads,buildings,and di ct�ipn. USE �omestic i]Monitoring ❑Heating/Cooling <br /> �M ;-. <br /> __ ___ __ __ _____ _ _ � �_,�Noncommunity PWS ��Environ.Bore Hole ❑Indushy/Commercial <br /> � I � ; � <br /> , , ; , ���Community PWS �J Irngation ��Remedial ���. <br /> --'--- —�----'--F----`-- � 1 Elevaror !�Dewatering �� <br /> w E CASING MATERIAL Drive Shoe? `,_'�,Yes �No HOLE DIAM. <br /> , , � . <br /> T � �\ �I Steel ��Threaded ❑Welded <br /> ; , ; ; 'h M�ie � iameter stic 1 <br /> , � Pla <br /> --.-----,----�-----:- 1 -�- <br /> I I ' ' �� CASING <br /> S �l,`_� D� We�ght Specifications <br /> �1 Mile—� �\\' �t _�,�__in.to�g�ft. �_Ibs./ft. ��� _�_in.to�ft. <br /> J l <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to _ft. IbsJft. __._ _ �in.to�ft. <br /> in.to ft. Ibs./fl. in.to ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEq{�_. OPEN HOLE <br /> ��235�'65th Plece Make$F�� �$ � From �b►To ft. <br />� /+,�,,,,�,,� Type /� ._ Diam._� <br /> ��e VLLIYC� t�9 55311 SIoUGauze sVlo Length �- T �- <br /> /��� Set between�,��__ft.and ��t. FITTINGS ~ f <br /> STATIC WATER LEVEL <br /> Measured from <br /> _��__ ft�'6elow [ I Above land surface Date measured �� <br /> WELL OWNER'S NAME/COMPANY NAME PUM;ING LEVEL(below land surface) t �� <br /> l�A <br /> � ft.after L hrs.pumping _g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION a <br /> F��Pitless/adaptermanufacturer �.:+�� � -�� `��� Model <br /> ❑Casing Protection_ _ ��12 in.above grade <br /> []At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well grouted ,�;Yes ;J No <br /> Grout materials ! I Neat cement�Bentonite �_�Concrete [,'�Other _ <br /> From_�.To__��tt. �__,__ �_i Yds. �,+Bags <br /> GEOLOGICALMATERIALS COLOR HARDNESSOF FROM TO From�__To 1Q5 ft�g��,],_f��ds. UBags <br /> MATERIAL From To ft. j�Yda �]Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> C�al ,v��� �r� � �� feet __ direction - type <br /> C��y a�� � �� �� PUIMPsinfected upon completion? Yes '�j No � <br /> J d <br /> rl� ��C��� ��� ��� �� 2�� [�Not installed Date installed -� � <br /> l l � <br /> Manufacturer's name � <br /> �te��iRRl g�$�T ��j lp� '��'� Model Number HP � 1 i.. Volts � <br /> C.T r <br /> Length of drop pipe /��/ �! ft. Capacity g.p.m. <br /> Type:`- Submersible iJ LS.Turbine ❑Reciprocating �]Jet ❑ <br /> ABAN ONED WELLS <br /> Does property have any not in use and not sealed well(s)? ��Yes '�, � o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? -�Yes ' 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 hue to the best of my knowledge. <br /> Use a second sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Don Stodola Weli Dri2lir►g Ct>., Ir�c. 1691 <br /> � Licensee Business Name Lic.or Reg.No. <br /> rfi ,R presen[a ive Sign�it�'� Certified Rep.No. Date <br /> Jilfl RA�11B <br /> , LOCAL COPY �7 o U l.l,`�. — — ——---- <br /> Name of Driller <br /> IC 140-0020 H601205-11(Rev.3/07) <br />