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WELL OR BORING LOCATION MINNESOTA UNIQUEWELL
<br /> MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG ND.
<br /> co„��YName WELL AND BORING RECORD � �,
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<br /> Minnesota Statutes,Chapter 103! � �� � � ���
<br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
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<br /> n.
<br /> GPS DRILLING METHOD
<br /> Latitude degrees minutes seconds
<br /> LOCATION: Longitude degrees minutes seconds i _Cable Tool ��,J Driven ! ��Dug
<br /> —— , ,Auger �otary .. j Jetted
<br /> House Num�St�eey N,��CitH,�d Zip Code of Well Location � or Fire Number i _
<br /> �1T �J� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �Rlo
<br /> Show exact location of well/boring in section grid with��X:' Sketch map of well/boriny,Jocation. From ft.To ft.
<br /> ��S howing p�r QBrty lines,
<br /> N =� ���r� oads,T)uildings,�nd;direction. USE �IDomestic �:�:Monitoring ��J Heating/Cooling
<br /> ,, �.
<br /> _1__ _; __L_ ._.__ ; �~ , . � > i I Noncommuniry PWS I�Environ.Bore Hole �.�':Industry/Commercial
<br /> —� �""�` � � :. �_,Community PWS =Irrigation ��Remedial —
<br /> --i_ 1 � :.
<br /> i �' i`�Elevator '���Dewatering �]
<br /> w ; ; , ; e � � � CASWG MATERIAL Drive Shoe? �]Yes �Vo HOLE DIAM.
<br /> --,--- --,--- --�----:- T i -
<br /> ;*.. '`,Steel [j Threaded ❑Welded
<br /> � � � � �F Mle _,�,� - � -
<br /> �.!S
<br /> , , , , � T '�� lastic ,
<br /> -'�--- —T— --�----�- � : .�
<br /> � � � � CASING
<br /> � � S � � � Diameter Weight Specifications
<br /> �--1 Mile—� �� _� in.to 1 Gt,__ ft. Ibs./it. _. Q_�in.to_�ft.
<br /> ZV'� f7w�
<br /> PROPERTY OWNER'S NAME/COMPANY NAME . in.to___...._ft Ibs./ft __ 6 ! in.to•'T+'!ft �r
<br /> �7 T 7.fL
<br /> in.to ft. Ibs./ft. in,to ft.
<br /> SCREE� OPEN HOLE '
<br /> Property owner's mailing address if different Ihan well location address indicated above. �7J�y_� �--�� ��
<br /> 4p�qL �s n�t„� Make�s".�'•w•�t .__.___.._ From ft. To ft. _�
<br /> laJL�F i'li�t� aT1tlCt Type�1�1'��5��.`� $�'� Diam._ � .
<br /> ����$� � S��I, Slot/Gauze_ . __ _.—_.—._ _Length_.�.�_�� __ �
<br /> Set between ft.and ft. FITTINGS
<br /> STATIC WATER LEVFL
<br /> 13r Measured from
<br /> � ft.' Below �]Above land surface� Date measured
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> �� ft.after •J hrs.pumpin g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ;�
<br /> '�+.1Pitless/adapter manufacturer a��;ta�a�e�ir.� . Model ,..:
<br /> �]Casing Protection_ �'I2 in.above grade
<br /> .At-grade(Environmental Well and Boring ONLY) �
<br /> GROUTING INFORMATION
<br /> we������ ��No ,� �
<br /> �� Grou�m'a er���* [c ryeni�8enronit t�oncrete �_�O er_ ___
<br /> 6aaa. 1 ��1 To Z ft. _ I ,Yds. ��Bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_,__ To ft. ,�'Yds ,J Bags
<br /> MATERIAL From To ft. f�Yds. I l Bags
<br /> _ NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> _ f��`�•- � ._feet {.�-� direction �e��S... type ���
<br /> Well disinfected upon completion? ,�Yes I I No
<br /> PUMP
<br /> � �Not installed Date installed_.._7�1.�� ._. _.. .._
<br /> Manufacturer's name_ ��'f+,�r _ .__
<br /> Model Number ____. HP__ ��_Volts_ �
<br /> Length of drop pipe __��7 ft. Capacity ._._ g.p.m.
<br /> 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 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. � �����g *��� �s��a� ^w'• ��# *�� �w,
<br /> �C 1 1 l.+f.7 1
<br /> Licensee Business Name � Lic.or Reg.No. �_,�.�
<br /> f�
<br /> �
<br /> �' d �presentative Signature Certified Rep.No. Date
<br /> �r�c��coPv
<br /> � � 3 5 0 6 �or�;ers� tdeil Co., r�/�o��a w. ��r�
<br /> Name of Driller
<br /> IC 140-0020 �
<br /> HE-01205-12(Rev.12/08)
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