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<br /> ` M/NNESOTA UNIQUE WELL
<br /> WE�L OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO.
<br /> � CountyNa e WELL AND BORING RECORD ����� �
<br /> � Minnesota Statutes,Chapter 1037
<br /> � Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> �`� c� l! 3 4� � �,,,�t1�- � " '� h � -�:.�/ r c�
<br />. GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds _
<br />� I Cable Tool �-'Driven �' ��Dug
<br /> Longitude degrees minutes seconds i �� �
<br />, _ Auger �otary,.,_ C Jetted
<br />� House Number,Street Name,City,and Zip Code of Well Location or Fire Number ---� .
<br /> +�� �� ,# � � � _ ���-?c°' RILLING FLUID p!L HYDROFRACTURED? [�.Yes o
<br /> r���
<br /> Show exact location of well/boring in section grid with . Sketch map of well/boring locatio . � �^�� � From ft.To ft.
<br /> Showing property lin ,
<br /> N roads,buildings,and directi USE �,�-�,y/mestic �]Monitoring ❑Heating/Cooling
<br /> � � � , � �_f.., .
<br /> __�____.:____L_ ___:_ [�Noncommunity PWS ❑Environ.Bore Hole �L]Industry/Commercial ���
<br /> =Community PWS ❑Irrigation ❑Remedial �
<br /> --'---�--- ---`-- --'-- ❑Elevator ❑Dewatering ❑ ' �-
<br /> '�'� E T CASING MATERIAL — '_,
<br /> Drive Shoe7 _j Yes ;�l�o HOLE DIAM.
<br /> I �� �` __Steel ❑Threaded ❑Welded ��
<br /> , , , , '/x Mile -
<br /> � � � � � , astic f]
<br /> --�-----r-- ---�-- ---�- � � �
<br /> � ASING
<br /> � � g � � s� - iamet�r Weight � Specifications {
<br /> F �j']/� �
<br /> �i M�ie� �in.to_����tJ'�r✓ft. �Ibs./ft. � s��in.to
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. J �/ to
<br /> `1 ��. �.
<br /> � qs�_u � � � in.to ft. Ibs./ft. in.to ft.
<br /> � '' OPEN HOLE
<br /> Propert owner's mailing addre�ss-i^f different than well bca``t^^io��n address indicated above. SCREEN �R('jYl d1„`�y!!'Y"`�
<br /> �t � � � ����11a y„��] Make From fL To ft.
<br /> fi z � �
<br /> Type y�Z� c1� � �v..i � � Diam. t' {'
<br /> f}�`��, �` 3 SbVGauze r ..�J �l�' �+` Length 7 � 7
<br /> � ,�""J" "��� �"���� �� �~ "'" � � Set between ft.and_-�y�ft. FITTINGS r ���
<br /> i
<br /> STATIC WATER LEVEL
<br /> Measured from
<br />� � �� ft� �low j.1 Above land surface Date measured �`�� �-�
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> � � � ft.after � rJ hrs.pumping w i� g.p.m. -
<br />�i . Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION '
<br /> i S� �
<br />�� r�itless/adapter manufacturer �}1�f-�-",-'-"'`''���odel
<br /> �. ��Casing Protection �2 in.above grade �
<br /> ❑At-grade(Environmental Well and Boring ONLY)
<br /> GROUTING INFORMATION
<br /> Well grouted es ,__J No
<br /> - Grout materials i_ Neat cemeM [�entonite ❑Concrete ';�Other _
<br /> From�To .��ft. __ '��/ ❑Ydjs�. g[,�ags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From �� "� To :.�1'.�.Jft. �C� IfAr�1�YUS: �K''Bags
<br />�" MATERIAL �
<br /> . From��To��. �( � ds. ags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION �)
<br /> ,.� � �..
<br /> } .. ;�- a � �.
<br /> � `� �'J f�� feet _ �"" direction :.:'� type
<br /> �+'') t Well disin(ected upon completion? es �'No
<br /> 1,,,,,,�[ N' ��r�t � �'"7 ��� UM P
<br /> { /y` , ❑Not installed Date installed r� �� � ��
<br /> �'� f��� �' � �� � ` +y� Manufacturer's name � . `<<">'�` -��r�✓
<br /> �� � (,_. , �j - - -� Model Number HP�Volts 1���
<br /> ,i��. �'..�}3���V. `� ��'. ��I 5:��". Length of drop pipe /4L)�. j
<br /> � �./ tt. Capacity g.p.m.
<br /> Type:��. ubmersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑
<br /> �� ABANDONED WELLS
<br /> Does property have any not in use and not sealed well(s)? ❑Yes [ o
<br /> VARIANCE
<br /> Was a variance granted Gom the MDH for this well? J Yes � o 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,if needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,eta - �
<br /> �n ,� �c�� �� a(�l� ff J,,,,; �'rk..
<br /> Licensee Business Name Lic.or R .No. ♦/ � `
<br /> �{,Ci r
<br /> __ _ _� �� ��
<br /> � e ese a i Sig a r - Certified Rep.No. Date
<br /> LOCAL COPY 7 �' � 1 �'-'"�U C' I� ��j' �-�C./��L '�
<br /> . � 0� -'--+� Name of Driller ��. � . . #�
<br /> IC 140-0020 HE-01205-11(Rev.3/07)
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