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, , . .- a . ;� ;� �_ '�"�. � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL ND. County Name WELL AND BORING RECORD 615 2 0 8 .�f�ti�![3p�tY Minnesota Statutes Chapter f03I Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed C?]CpuC1 t1.ti 23 1� ii�iAi,�. �ti�: 5w 2t�it{ n l��J�'�ii House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD . �� Ii�r�t �a2�$ C�rono 5�356 ❑ CableTool f7 Driven ❑ Dug � ❑ Auger C�otary ❑Jetted Show exact location of well in section grid with"X". � � Sketch map ot well location. ❑ . Showing property lines, �•r,,,,^4 roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES I�NO N "�- � � i i ' �� 511��1 ��1.'�x FROM fl.to ft. -� -i- -i- -i- H �. � ,,...+"'��"�' t USE ❑ Monitoring ❑ Heating/Cooling j i i i i �omestic _i_ _a_ _�_ _i_ ❑ Community PWS ❑ Industry/Commercial � i i � � �C ,` ❑ Irrigation ❑ Noncommunit PWS ° w E T � . j L � ❑ Test Well y ❑ Remedial i i � � ❑ Dewatering ❑ i i i i +�ZI M_ie CASING Drive Shoe? �es ❑ No HOLE DIAM. _i i i i_ � � �teel Q�Fhreaded ❑ Welded i - i- -i - -i . _ ...�_.,,,,,, � �� .1 ❑ Plastic ❑ S r'`'i.. ( � i (/�t.iE F-1 Mile� , C ljl�C. i . '---_____,a..... s_.�.M �.�tlL, ` CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME 4 in.ro�_��ft. Ibs./ft. �in.to L� ciartc strot�l ��.�o K. �bs.�n. �t�, 'l Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. C�U ��.f�LC� t'�O�.a'�. SCREEN OPEN HOLE ' j�3V �•1�• �t��i1`�.a*r� �1��• Make .T��en��_ _ from ft.to ft. � ��,�°?.��i�I � ��3�3. TYPe ��_��'.�i� Diam. �+t : SIoVGauze j Z _ Length �� Setbetween �,"!�'1 ft.and ��5 ft. FITTINGS: �f IB'dL�er STATIC WATER LEVEL , WELL OWNER'S NAME �� ft. �below ❑ above land surface Date measured PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. �� ft. after 3 hrs.pumping �V g.p.m. WELL HEAD COMPLETION � q�itlessadaptermanufacturer ��iite�rater Model `v��4 ❑ Casing Protection ❑ 12 in.above grade , ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? f]�'es ❑ No HARDNESS OF Grout Material eat cement ❑ Bentonite ❑ Concrete ❑ Hi h Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � �� to 9 from 7 ft. �_ C�yds. ❑ bags . �g�� j�� r�� .�„�� from to ft. ❑ yds. ❑ bags from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION � i%i�� -�� ''�• '� �'� E� teet i'l1Ai direction��'� 1�11`e�i�' Well disinfected upon completion? [X,Yes ❑ No �tat�dy �3.��[ �lu� ��a. 1 �i3 PUMP jj��(j�� ❑ Not installed Date installed 1��`�/�� san�f cla�r ra+d CUUrSc"3 � �13 Manufacturer's name �l@L'IEl�O�'.O�' �dYlt1#,� C1dY/� Y�ll�yw t�igt�. y ��(� Modelnumber HP a vons 1�� Length of drop pipe j 4� tt. Capacity �� g.p.m. �`la✓ jj,],Lj$ jt1�(�• 1� 11� Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ l ) ABANDONED WELLS , . .�'L�IId✓ Cla� b�jl� jjj�'�. �i f.'�� Does property have any not in use and not sealed well(s)? ❑ Yes �o � i VARIANCE �� �J�.al.Ga ��,�� g�g� 24r `�� Was a variance granted from the MDH for this well? ❑ Yes C3�lo WELL CONTRACTOR CERTIFICATION � 3 Use a second sheet,ilneeded This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. I REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. 1:�3:iltl�� t.irlV�a1 irc�� L�J1 ta .�� t�,�.`j 4YC�.1. {31'lllltlt3 L71�� � Licensee Business Name Lic.or Reg.No. � , � . ..'�-. _ /` .. . � . .-,.r,�.�"' t., �;.��d____ �� - � 7 _1=��# ,_ �!� , Authorized Representative Signature Date � .. �t+a�rt �s. �tiuci�ia. Jr. ll/��ijya Name o/Driller Date � LOCAL COPY 615 2 0� HE-01205-06(Rev.9/97)