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M/NNESOTA UNIOUE WELL
<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
<br /> County Name WELL AND BORING RECORD 7 7� � 5 3
<br /> ��ep�� Minnesota Statutes,Chapter 1031
<br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> t}rvr�o lI7 23 OS P3F ?�,�NS ,� 229 " —
<br /> GPS DRILLING METHOD
<br /> Latitude degrees minutes seconds
<br /> LOCATION: ' -'Cable Tool � �Driven Dug
<br /> Longitude degrees minutes __ seconds - �
<br /> [�Auger ��`Rotary . �Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number '�,
<br /> .7�JS Gi�i[�;) iii�� Rd� L„riy«{�7 SS3SC� DRILLING FLUID WELL HYDROFRACTURED? �'�Yes C,�1Uo
<br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring lo a� ����e
<br /> Showing propert lin From___. _ft.To ft.
<br /> roads,buildings,and dir dtiOR. USE Monitorin I-'Heatin /Coolin
<br /> N �Domestic I� 9 9 9
<br /> � � � � ��� �� ❑Noncommuniry PWS �. =Environ.Bore Hole �._�Industry/Commercial
<br /> --'-- -'------Y-----•-- � �.
<br /> �-�' �>,,v' _ _Community PWS ��,-,Irtigation L,Remedial
<br /> ; 1 1 I i -��� `, -,.
<br /> --- - ---- --- -- � L'�,Elevator �,_ ,Dewatering __,
<br /> w ; ; ; ; e� � CASING MATERIAL Drive Shoe? ❑Yes ;h�,No HOLE DIAM.
<br /> --'--- --�""" """�-- ---'-- � �� �"Steel �1 Threaded Lj Welded
<br /> ; ; � : �� ��e �,� �—
<br /> �M i � ,�Plastic L I
<br /> --�-----�--- ---%- --�- 4 .
<br /> CASING
<br /> S � Diameter Weight Specifications
<br /> F--1 Mile-� �' � in.to_.���__fL . Ibs./tt. _____ v# in.to �`n�' ft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME � _ in.to ft. Ibs./ft. ��i in.t��7 ft.
<br /> �=�e� ��$ YL.�..�, in.to ft. Ibs./ft. in.to ft.
<br /> ;JCi A7 V V
<br /> SCREEN OPEN HOLE
<br /> Property owner's mailing address if dif�erent than well location address indicated above. � --
<br /> 2�45�J 23cd Ave r� Make� From ft. To ft.
<br /> {� �T �je�y�L Type ��-�_���� ��_ Diam.__ :
<br /> P��=it: 1��'� " - "Y� SIoUGauze .�_ _ _ _Length ���
<br /> Set between ft.and ITTINGS � p
<br /> STATIC WATER LEVEL
<br /> 3�� Measured from�����..�
<br /> L ft. Below ��I Above land surface Date measured �+ '�� +�
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(bel w land surface)
<br /> ��� ft.after___ ��� hrs.pumping +�� g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �'- ',-'�• __�-_..
<br /> �Pitless/adapter manufacturer -' del
<br /> ;Casing Protection ._ �'12 in.above grade
<br /> �At-grade(Environmental Well and Boring ONLY)
<br /> GROUTING INFORMATION
<br /> G olut m�aterf"'�a s�`��eat cement�$entonit��.�C,oncrete ��Other x
<br /> �'��I'��`g From 5`3 To � ft. �'�� 1 Yds. �, �Bags
<br /> HARDNESS OF ���� ��To��._ft. � � j�,Yds. �Bags
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ,
<br /> From _To_._ ft. �I Yds. �,�Bags
<br /> ? /� NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> �.'1��T y��l� ��_ � �tJ �-^.. "�.) feet �" '-f direction ..._.,,��-_ ' type
<br /> Well disinfected upon completion? �,�'es I�No �
<br /> clag �;r8y soft 10 14C3 pUMP
<br /> �� ��Not installed Date installed �� ,_ '"� "' Y '���
<br /> �r�� sof t 140 2�?3 ` `, . ,•_ . .�
<br /> ManufacturePs name " �
<br /> . t
<br /> �.i8y {�� �ct �� .y�� Model Number ���"HP ,... Votts -�'" � ��1 �
<br /> 1 U l L .
<br /> Length of drop pipe '��f� �� ft. Capacity g.p.m.
<br /> �t�C'� b� �Qf t Z'�,'L ",�,'�� Type:'� Submersible �LS.Turbine []Reciprocating [�Jet ❑ _
<br /> ABANDONED WELLS
<br /> Does property have any not in use and not sealed well(s)? '�.�Yes �No
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? ���Yes f�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,etc.
<br /> Z�on Stodol�. �IeII Dril23n,�Ca., Inc
<br /> Licensee Businyss�Vame Lic.or Reg.No.
<br /> �� (�
<br /> i, �`� `�� .1 Y. -I !'� � �':��
<br /> ,Eertified Representative Signature Certified Rep.No. Date
<br /> C�t�k Moore
<br /> LOCAL C(�PY � � �:.� J � Name of Driller
<br /> IC 140-0020
<br /> HE-07205-12(Rev.12/OB)
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