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WELL OA BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AEND BOR/N��G NO. ELL
<br /> ' co��tY Name WELL AND BORING RECORD 7 g g 2 3 8
<br /> v_�� Minnesota Statutes,Chapter f037
<br /> [7Ci�iC
<br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> 4rono 217 23 S 1� NR,2�E ,, 230 n 4-2G-12
<br /> GPS DRILLING METHOD
<br />` �OCATION: Latitude _ degrees minutes seconds
<br /> Longitude degrees minutes seconds ❑Cable Tool ❑Driven
<br /> - ❑Auger �otary
<br /> House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑Other
<br /> 3.7�� C�R�I� 1'�ill 1�.� Ot�b Sg3�b �DRILLING FLUID � LL HYDROFRACTURED7 ❑Yes _ o ��
<br /> Show exact location of well/boring in sectio with"X° Sketch map of well/boring location. Q$ter From ft.To ft.
<br /> Showing property lines,
<br /> roads,buildings,and direction. USE
<br /> N ,�Domestic ❑Monitonng ❑Heating/Cooling
<br /> __J__ __�_____________ �� � ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ��
<br /> �f Community PWS ❑Irrigation ❑Remedial
<br /> --1--- --;-----F—--f— �._,l Elevator ❑Dewatering ❑ '�
<br />'- W , , , ; E � CASING MATERIAL Drive Shoe? ❑Yes ,�No HOLE DIAM.
<br /> �� , , , T ���:
<br /> --,-----.------�-----:--
<br /> '4�-[��-�Steel�.� ❑Threaded ❑Welded
<br /> � � � � �
<br /> � , , , , '/Mile .'��.PI �]
<br /> , , , , I astic �
<br /> --;-----�------�-----�- 1
<br /> ` F CASING
<br /> � � S � � � Diameter Weight Specifications
<br /> �7 Miie� ��y(�,�, � in.To `lv ft. ---+� Ibs./ft. � in.To �ft ��
<br /> PROPERTY OWNER'S NAME/COMPANY NAME _in.To___ft.�� Ibs./ft. �in.To��ft . -.,;�
<br /> S�� **/+ __in.To ft. Ibs./ft. in.To ft
<br /> ZY'��� OPEN HOLE
<br /> . Property owner's mailing address if different than well location address indicated above. SCREEN _ -�-
<br /> 7�4V1 ��r�t� ���� +7�f� �iJV Make— •���t -_ From ft. To ft. y
<br /> '' �tt / t Type St8�I1.[��' _���1 Diam.
<br /> i'7LL��1�.4� � ���1�4 -- ��[�. _ Length 1}� ♦ � .
<br /> SIoVGauze ___ �
<br /> Set behveen ft.and tt. FITTINGS * !
<br /> �••�t� IQl� STATIC WATER LEVEL
<br /> Measured from
<br /> ��� _ft.,�3elow j]Above land surface Date measured��
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> ��� ft.after � hrs.pumping_ �" g.p.m.
<br /> WelUboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION sj t�t�r
<br /> Pitless/adapter manufacturer��lYl Model
<br /> ❑Casing protection __ �12 in.above grade
<br /> ❑At-grade ❑Well House L]Hand Pump
<br /> GROUTING INFORMATION(specify bentonite,cemenbsand,neat-cement,concrete,cuttings,or other) z_
<br /> Material[�a�tVf,iite From � To SO n. 3 ❑Yds. �ags
<br /> Matenalffit 4lAl '��_��To���ft. ❑Yds. '�_J Bags
<br /> HARDNESS OF Material From To ft. ❑Yds. L;Bags
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
<br /> Driven casing seal From To Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> �0 i1 bl� ��t Q ` �� feet � direction ""r�a� type
<br /> ^ Well disinfected upon completion? �Yes ❑No
<br /> �� ���� ��j$� G � PUMP
<br /> ❑Not installed Date installed ��_��
<br /> :.,. C28 I��t�!! �� �
<br /> Manufacturer's name ��� ___ ___.__
<br /> C� � �� � ��� � ��� Model Number HP 1.5 Volts__
<br /> Lengih of drop pipe �C77 ft. Capacity g.p.m
<br /> �� a �2� ��L ��C Type:�Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
<br /> ��=3 •�E� � qgANDONED WELLS
<br /> �7 —_�i � �ij� 1 c! Z•�/� Does property have any not in use and not sealed well(s)? ❑Yes�No
<br /> 1 :f�iAd �lj• 1'» '��� 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 true to the best of my knowledge.
<br /> Use a second sheet il needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,g�c���'*/�B
<br /> R � Don Stodals i�ie1.1 Dtillft��, Ccs,. It�. 164�_
<br /> 20�� Licensee Business Name Lic.or Reg.No.
<br /> F�B � � � _ 8-22-22
<br /> C.�/ ORONO -- — - =
<br /> j'� I � resetitative�6Cgnat re ` Certified Rep.No Date
<br /> Rob Sttadola
<br /> �_�����L����.:,, 7�8 2 3 8 -
<br /> Name of Driller
<br /> IC 140-0020 HE-01205-13(Rev.11/10)
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