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<br /> � MINNESOTA UNIQUE WELL
<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
<br /> CountyName WELL AND B�RING RECORD � 6 ��.�.2_�.�
<br /> ��i� Minnesota Sta#iites,Chapter 1037
<br /> Township Name Township No. Range No. Section No. Fraction WELY780RING DEPTH(completed) DATE WORK COMPLETED
<br /> t?tocio 32i 23 OS � ,� ,U '*�� � i8-(!S
<br /> GPS DRIL:LING METHOD
<br /> ��� LOCATION: Latitude degrees minutes seconds _
<br /> Longitude degrees minutes seconds ._ Cable Tool '�J Driven � '�Dug
<br /> — - �Auger �Rotary ['Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number �,—_� ��
<br /> J4'iV C7�I� 1'�i�L� � vLVi� �Sb DRIL�fNG FLUID WELL HYDROFRACTURED? r'Yes ; o
<br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. ��?'�-� �t��l From ft.To ft.
<br /> -} Sho p perty lines, �_� ��
<br /> ' .y .. r uil s direction. USE• �' � � ,
<br /> N '�..,,)� -.+..��.a..._.ha-%'---��� �� ���,�Domestic '�Monitonng �i Heating/Cooling
<br /> __.___ __._____L_ ___:_ �-����,_��.Noncommunity PWS ❑Environ.Bore Hole [�Industry/Comme'pcial -�
<br /> �' I Communiry PWS ']Irrigation r Remedial �
<br /> --'-----;-----`-- ---`-- i Elevator �'�Dewatering -� � �
<br /> W � � E MATERIAL Drive Shoe? [I Yes o HOLE DIAM. �
<br /> _ _
<br /> T � CASING � ;
<br /> �-- F- ---%-- � `. , , _. � � .
<br /> "'� �Steel _Threaded ❑Welded
<br /> , , � 'h Mile . lastiC '-
<br /> , , , , 1 � � _
<br /> --.-----,-- --.-- ---:- . -
<br /> v3$" _ , CASING
<br /> g � - iameter Weight Specifications
<br /> �1 Mlle� �� �,I �in.to_�ft. �.7bs./ft. , _�,,,�� �in.to�. .
<br /> ��p �
<br /> PROPERTY OWNER'S NAME COMPANY NAME in.to _ it .___IbsJfL _. __ _ �in.to (.1/i7t.
<br /> B�•,Qt� /+•,��,t�ti� in.to ft. Ibs./ft. in.to ft.
<br /> � wu�a OPEN HOLE
<br /> Property owner's mailing address if differeN than well location address indicated above. SCREEN
<br /> 22d15 � 7 Make a� ____._ From ft. To ft.
<br /> i7iI7[lct� � J��� TYPe ��aiii��,� �t-i Diam.----_—
<br /> ! SbUGauze �$,�8 _____ Length� ,* ({�
<br /> Set behveen ft.and it. FITTINGS
<br /> STATIC WATER LE EL
<br /> /� Measured from
<br /> 2V-7 ft.i elow n Above land surface Date measured ��
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> 37� ft.after ` hrs.pumping �7V g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION },,• ���y�
<br /> [�,(`S itless/adapter manufacturer_t�����^�'�'*s'�'"�^�Model
<br /> �..J Casing Protection ��Q2 in.above grade
<br /> � ]At-grade(Environmental Well and Boring ONLY)
<br /> GROUTING INFORMATION
<br /> Well grouted '�Yes L�No
<br /> Grout materials �,.�Neat cement�entonite � -Concrete ❑Other.}
<br /> From To y�� . �7 � I Yds � ags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From � To I7ifit. �RL�����I�Bags
<br /> MATERIAL From__�To__ GlJ[.7f1. � ❑Yds. � ags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> CIa bc�m aOft 1 )��
<br /> J 'Q�feet � direction � � type
<br /> t �y Well disinfected upon completion? ' es ❑No
<br /> Ct�l aQ,{,{, � PUMP
<br />-� � � �i Not installed Date installed �'"� ` ��� �6✓
<br /> C�$ �'"""" ��t � Manufacturer's name �--a!� ��.."�..J`✓
<br /> Model Number HP .J Volts ��
<br /> cla bc�c�m aQft I 1 i,, '7
<br /> Length of drop pipe /Y / ft. Capacity g.p.m.
<br /> � L.� �A, � Type: Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑
<br /> � l�� ABANDONED WELLS
<br /> � Does property have any not in use and not sealed well(s)? �-I Yes I o
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? �'�Yes � o TNri
<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 sheeG if needed. ���'�S• tL*1 � �r�e�s� "�a i�• a diviaion of
<br /> } REMARKS,ELEVATION,SOURCE OF DATA,etc. Y�C�1 i����1�
<br /> Dc�ei Stodols Weil Drfllfa� Co., Ix�c. 1691
<br /> __ - - __ _ __
<br /> Licensee Business Name Lic.or Reg.No.
<br /> ��� 4C�
<br /> �ie resentative Sigrf�iture � Certified Rep.No. Date
<br /> LOCAL COPY 7 �O 6 C. V __._� �� _-
<br /> Name of Driller
<br /> IC 140-0020 HE-01205-11(Rev.3/07) �
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