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T MINNESOTA UNIQUE WELL WELL OR BORING LOCATfON MINNESOTA DEPARTMENT OF HEALTH AND BORING NO co„�tv Name WELL AND BORING RECORD -7 8 8 2 2 7 Minnesota Statutes,Chapter 1037 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED �� 23 � — — GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longi[ude degrees minutes seconds ❑Cable Tool I�Driven -- ❑Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑pther � 3315 Grat� FIi21 �td, Orcyno 5535b DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X° Sketch map of well/boring loca n. �teC From ft.To ft. Showing property li s, N roads,buildings,and direc n. USE �Domestic ❑Monitoring ❑Heating/Cooling __�___ _J______L__ ___t__ [��Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial � ,. � � � � y �_! ommun y WS Irrigation emedial {�y� C it P ❑ ❑R �"�'� --i-----;-----F-- ---�– � []Elevator ❑Dewatering ❑ � � � ' ' / '�'� , � � , E T / CASING MATERIAL � � HOLE DIAM. , , , , �S Drive Shoe. ❑Yes No , --;-----;-----�–---%-- ' / 4 '�•'�❑Steel ❑Threaded ❑Welded , � , , 'h Mile / stic . i J�Pla ❑ ', --�-----T–--�-- --�-- / � f � � . CASWG � � � g � � i / � � ; Diameter Weight Speci(ications 1 / s� f� �—iM�,ie� � � � � ( � � in.To�l`� ft. �� IbsJft. ��"in.To �ft � / � PROPERTY OWNER'S NAME/COMPANY NAME in.To_ ft. Ibs./ft. in.To�ft tfiarle$ t�dd DF�vo in.To ft. Ibs./ft. in.To ft SCREEN � OPEN HOLE Property owner's mailing address if different than well location address indicated above. . 1�0 �"'�� A� � Make ��n��t�� From To ft. � p2�ti�f � SJ��7 TYPe__— -- -- Diam. , ' – ' ' SIoUGauze sd20 Length� ____ ; Set between_ ft.and it. FITTINGS��_ P�343f,-04500 STATIC WATER LEVEL Measured from__ ft. Below [�Above land surface Date measured__ � WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 2� ft.after � hrs.pumping � q.p.m. Well/boring owner's mailing address i(different than property owner's address indicated above. W LLHEAD COMPLETION �te�ater Pitless/adapter manufacturer__.._____ ___ Model �;.. > ❑Casing protection �12 in.above grade ` ❑A4grade ❑Well House �]Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,coLncrete,cuttings,or other) Mffierial �MtV[iit�r�omt �0q To_ S�q ft. `f ❑Yds. �Bags Material �tYiSl ��il Rl To �2.? ft. ❑Yds. ❑Bags HARDNESS OF Matenal___ _ _From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags �n NEAREST KNOWN SOURCE OF CONTAMINATION ♦ C�a�1 ye12{� �i� � `� �� feet � direction �tiC type t Well disinfected upon completion? _,Yes �.No C�Sy �lU� �JLL� � � PUMP 1 CI.+II �� $� l9CU.1� 80 lb5 I�Not installed Date installed �—j�� ___ _ Y " � Manufacturer'sname �'�{`�1$efP_C__ _ C��/�� ir� 1___y �S� 4�yC Model Number HP 3 Volts 2.31T J u iKrLT7. a�7 Length of drop pipe Z� ft Capaciry g.p.m g«Qe1f=� bt•�Y �� lgs ZI1�' Type�(''I Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS s��a�ypl b�l I�Clti� 'Li� �I Does property have any not in use and not sealed well(s)? ❑Yes �No ��• , VARIANCE Was a variance granted trom the MDH for this well? ❑Yes �No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. - REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stcxiolaf[�eil Dcilling Co.i Icu. 1691 Licensee Business Name Lic.or Reg.No. ,,, � 1-12-I2 -� --_ _ _ -- 'resentative Signature �Certified Rep.No. Date . 7 8 8 2 2 7 �`k s`°�°lg �o;x+L C.��P`� - --- Name of Driller IC 140-0020 HE-01205-13(Rev.11/10)