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.t. . � _ *w�. x WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELL AND BORING RECORD 6 7 3 8 6 3 He�ne in Minnesota Sfatutes Chapter 103i Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed R. Ocano 21$ 23 32 . �. �. 29Q 1-i5-02 House Number,Street Name,City.and Zip Code ot Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ riven '7 Dug S75 �okesh Rd Qr�'�'1� 55359 ❑ Auger �Rotary i� Jetted Show exact location of well in section grid with"X". Sketch map of well location. f7 Showing property lines, roads and buildings. DRILLWG FLUID WELL HYDROFRACTURED? ❑YES NO N auper gel-x i , i i FROM_ __ft.to __ ft. _i_ _i_ _i_ __ USE ❑ Monitoring ❑ Heating/Cooling � i � � � �l Domestic _i_ _�_ _a_ _i_ �. ❑ Irrigation � Community PWS ❑ Industry/Commercial i i i i � ❑ Noncommuniry PWS ❑ Remedial W E T� �~� - t�' f7 Environ.Bore Hole _ _-- i � � i I '� ❑ Dewatering i i i -r '/ZM1e � � '`� CASING Drive Shce? es ❑ No HOLE DIAM. _, i _L_ _i_ � �� 1 Steel �Threaded — ❑ Welded i - i- i i �� ❑ Plastic ' O �1 Mile� :)i�,� !�� CASIN�DIAMETER �� WEIGHT �� A PROPE TY OWNER'S NAME v Lp� T in.to ,,. Ibs./ft. ��i .to ft. L$(� SCll�t� G�d�t' ln�'s _ in.to fl. IbsJft `�y�?�in.to ff. �� Pro erty owner's mailing address if different than well location address indicated above. __in.to ft. Ibs./ft. „) /i��$ _ft. 9 0 2t�305 Lakeeiew Ave SCREEN OPEN HOLE Eaceisior, MN 55331 Make from 25�i n.to 290 h. Type .Diam. SIoUGauze Length Set between ft.and ft. FITTINGS: STATIC WAtTER LEVEL ' WELL OWNER'S NAME 12Y ft.l�below ❑ above land sur�ace Date measured__ '�_� 5— 2 PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. �__�,_$Q_ __ft. atter_ ��__hrs.pumping �__g.p.m. WELL HEAD COMPLETION �hi t ewa L e r ^ ❑ Pitless adapter manufacturer_ ______ ____ Model __ _ � C7 Casing Protection___ ___. _ ❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING WFORMA�N Well grouted? Yes r7 No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material [1 Neat cement ❑ Bentonite ❑ Concrete �High Solids Bentonite MATERIAL from_ _ �_to__._3_Q_ft. � _�.__ ❑ yds. �bags from__�_to�_�ft. Q�� O�slq bags from _ to_ ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTA�tAINATlO� �--�� feet �� direction clay gray �roft � 25 lo '_- ' ' � ' � --n�� Well disinfected upon completion? '�Yes ❑ No � gravellcl8y gray aoft �00 I55 PUMP r 4 Cl Not installed Date installed ��J�O� Cl8yf8j-�t O�gJ "'��lf 15� 2�1 Manufacturer'sname ��ffi�� C� �C� Model number HP � Volis �Q granel/clay grap �aedium 21I 245 . --!- y?-- -- Length of drop pipe�J�,y l ____. ft. Capacity g.p.m. sandstone/shsl g[$y�� en 2�'S �fA� Type ❑ Submersible C7 LS.Turbine ❑ Reciprocating ❑ Jet ❑ ___ G7 �� u� ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes 1�No VARIANCE Was a variance granted from Ihe MDH tor this well? ❑ Yes � No TN# WELL CONTRACTOR CERTIFICATION Use a secondsheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,eta The intormation comained in this report is true to the best of my knowledge. Don Stodol$ W�II Drilling Co. , Iuc. 2 172 -- -_ - �Li�ss Na.......ii%.._. --' :or Reg.No. ---- �"' �C 9-25-42 Authonzed Represent6tive SignaNre Date Duan e Mathe�ra 1-15-fl2 � Name ol Driller Date LOCAL COPY 6 7 3 8 6 3 HE-01205-07(Rev.?J99) IC#140-0020