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a MINNESOTA UN/QUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. ' County Name WELL AND BORING CONSTRUCTION RECORD ��3� 3� � J R Minnesota Statutes,Chapter 103I �— � � Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 23 t32 NE ?V� SW�� 172 " 27-1.6 � GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven `�Auger '6dRotary House Number,Street Name,City,and ZIP Code of Well Location []Other �� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/bonng in section grid with"X" Sketch map of well/boring loc tion. �t�C From ' fl.To ft. Showing property ines, N roads,buildings,and dir tion� USE No cosmmunit PWS ❑Env ronl Bore Hole'�� Heating/Cooling I I I I ��Industry/Commercial - -- --- ---- --- - +� Y ❑ -'--- , � _ . _ ; � ; � ��Communiry PWS ❑Irrigation ❑Remedial , � , , � , (=;Elevator Dewatering � w ; ; ; ; e T CASING MATERIAL Oeo HOLE DIAM. Drive Sh ❑Yes o --'-"" "-�--- ---�-- -"'''" I "'� ❑Steel []Threaded ❑ elded ; ; : ; ,1M ; ; ; ; w� �� Plastic ❑ ";'____�___ __;"___�_ ile ` � � , � r CASING � � S � � � �`� Diam/eter Weight Specifications �--1 Mile----i � `i' in.To �� ft. Ibs./ft. � in.To�� ft. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. "'� in.��ft. '��eC Tj�s in.To ft. Ibs./ft. in.To ft. Property owner's mailing address if ditferent than well location address indicated above. SCREEN OPEN HOLE (i4W �1��1� T�� S Make �?��n�� From ft. To ft. �i� MMt�II 55340 r.. TYPe �_s—t _�_1 Diam. .N � ... .; ._� .gLii.LiTr�.� 3iC� ,.�.,, :�� SbUGauze Length Set between � � .and it. FITTIN STATIC WATER L� �;,` `� va ��q� �� Measured from i ft. � Below n Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME n PUMPING LEVEL(bel w land surface) `��eP �`.r ��;E� ��ft.after � hrs.pumping '� q.p.m. i Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �j Pitless/adapter manufacturer Model ❑Casing protection �12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-�ement,concrete,cuttings,or other) Material ��tQ�t�rom v To ��✓ft. � ❑Yds. �j(Bags Material natueal ��1 Sa To 1� ft. �Yds. ❑Bags HARDNESS OF Material__ From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS CO�OR MATERIAL FROM TO Driven casing seal From To T Bags NEAREST KNOWN SOURCE OF CONTAMINATION I, clay brc�en mec�3.wn 4 38 , `� ' / A ..� feet /V direction'._�_�`-" �•:.:-�..1.-s-r1y .��j�•18�' b��Z �d�� `+5 b� Well disinfected upon completion? Yes ❑No .�:.� �+..j a PUMP �[A�.f��el 6.11aL+Li $Q�t 7C� C�[� ❑Not installed Date installed f' Manufacturer's name �'i(`�;Q��L ��/Ci��/ �rr�y ��t �Lf� LG� ModelNumber HP 1NJ Volts {' Len th of dro i e 1�1C ft. Ca acit m t ,��.�71 11 tG 9 PPP�� p Y 9P C1$J�`S$� t)�� 1'l�f�t�11 LSV 1V� Type: Submersible ❑LS.Turbine ❑Reciprocating �Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? �Yes No VARIANCE Was a variance granted from the MDH for this well? [�Yes No TN# WELL CONTRACTOR CERTIFICATION '�. This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. tkm Stadola �de11 Drilli = Dnc. 1691 Licensee Business Name Lic.or Reg.No. / . . _.--� .�', 12—$�-16 C ie e n ative Sign ure " +'' C�rtified Rep.No. Date Rab Stodola � L06AL COPY H 2 3 4 3 O Name of Driller � ID#52603 HE-01205-15(Rev.e/13)