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�► ; WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUE WELL NO. � County Name WELL AND BORING RECORD P ( 2 � a33 � in Minnesota Statutes, Cha ter 103I Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed ` 4cono 128 23 27 �� 185 `� 8-26-f)S GPS DRILLING METHOD � LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds �Cable Tool �'Driven .Dug [;Auger �otary ❑Jetted - House Number,Street Name,City,and Zip Code of Well Location or Fire Number � ' 1925 Lakeviev Tecrat:e O�OL� 553 b DRILLING FLUID WELL HYDROFRACTURED? _,Yes o 9 Show exact locatfon of well in section grid with"X". Sketch map of well location. �t�3t� FROM ft.TO ft. �:a S�hoJw�pg property lines, oads and buildings USE N � � [J Monitoring j]Heating/Cooling ' I I ; I � �� ,; �Domestic �,�'�Environ.Bore Hole �J IndusVy/Commercial -� --'--- --J--- ---`-- ---`-- ' ;]Noncommunity PWS �._�Irrigation `�..Remedial �'Community PWS �_�Dewatering ❑ CASING . HOLE DIAM. w e T ` ( Drive Shoe? �__�Yes �No Ih�" j '��Steel {_=�Threaded 'L;Welded 'h nnlie �y+ ""'^"`�� ,rplastic � _ : ------ ------ --�-- ---:-- 1 � CASING DIAMETER WEIGHT : , , S , , �1 Mile—�{ —`'�in.to_._�ft. 4 Ibs./ft. �__in.to_lE/ft. in.to ____.. ft. Ibs./ft �in.t�f7J ft. ' F . PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft. � aillG iQCs SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make FROM ft TO tt. ��y+� t1A�,c• �+ S�S�Ytt@913��— n: alJlJ7 1 A1�RL76 JPu TYPe— - -- — Diam. � -- — �3.l�LiV MN 55328 SlotlGauze_ �__ Length �f „t, )�! s Set between ft.and ft. FITTINGS STATIC WATE L � 1�� ft.I�ielow �._;above land surface Date measured U�Lv�tl� � PUMPING LEVEL(below land surface) : WELL OWNER'S NAME/COMPANY NAME �' _ 1�,'r}_ _ft.after Z hrs.pumping 1,� g.p.m. WELL HEAD COMPLETION �� Well owner's mailing address if ditterent than property owners address indicated above. �pitless adapter manufacturer_ 1'�1��@ii$.�.@1' Model �Casing Protection �2 in.above grade �,Abgrade(Environmental Wells and Boring ONLY) GROUTING INFORMATION Well grouted ,1_,�'es �r]No Grout material _Neat cement ❑Bentonite �. J Concrete ,�-ligh Solids Bentonite from�to�ft. � ❑yds. [*6ags from�__to ��S ft.j�_��c�. ��.,bags � GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft [;yds. (]bags � MATERIAL NEAREST KNOWN SOURCE OF CONTAMINATION - _. ,.� '"� l.�, �v_. • ,ryPE � C� �'+� O �O Y✓'�✓ feet �� ► direction � EaG'UJ. ' Well disinfected upon completion �Yes '�_�No ��.r.J i..,:_.�;., .y-�.�- @�.ZOii C � U7�iL� lO 1V17 PUMP T�S ,Not installed Date installed � � e r�,� �t� �t� Manufacturer's name �� iACRa.i OlJ � Model number _, HP � Volts �`� � �� 65 185 Length of drop pipe �f�� ft. Capacity g.p.m. Type: -� ubmersible I��LS.Turbine [Reciprocating ❑Jet ❑ ABANDONED WELLS � Does property have any not in use and not sealed well(s) `_]Yes o VARIANCE Was a variance granted from the MDH for this well? r]Yes o 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,if needed � REMARKS,ELEVATION,SOURCE OF DATA,eta � Stodola 'Well Dciilfn,�.Ca�� I�IC zn7a Licensee Business Name Lic.or Reg.No. _r,."� i1-9-05 ut rized Representative Signature Date Ji� 1Coh2s LOCAL COPY 7 2 � � � 3 Name ol Driuer HE-01205-08(Rev.5/02) . IC 140-0020