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<br /> ` MINNESOTA DEPARTMENT OF HEALTH M/N AND BORINI�G NO. ELL
<br /> WELL OR BORING LOCATION
<br /> � County Name WELL AND BORING RECORD � � p 0 4 6
<br /> ��� � Minnesota Statutes,Chapter 1037
<br /> Township Name �. Township No. Range No. Section No. Fraction WELUBORING DEPTH(comple[ed) DATE WORK COMPLETED
<br /> Orcmo 117 23 07 � Nt� P�3�, lI0 f� 12-32-49
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds , �
<br /> Longitude degrees minutes seconds . ��Cable Tool '��.I Driven �_J Dug
<br /> . �'Auger ���Rotary �. �Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number L..I
<br /> DRILLING FLUID WELL HYDROFRACTURED? i___J Yes �.Ao
<br /> Show exact location of well/boring in ction grid with"X" Sketch map of well/boring I cation. �'�intonite From ft.To ft.
<br /> Showing proper linea�� ---
<br /> N roads,buildings,and di ection: USE i=ynomestic
<br /> , �., �,. ❑Monitoring ��Heating/Cooling
<br /> ,� _J__ ._1.___L__ ._:__ `,, ��{�' ',_Noncommunity PWS ❑Environ.Bore Hole U Industry/Commercial ��
<br /> �•' �
<br /> .,._ ,���.''��'''''''''�'`'^''�"� , ,^Community PWS �,�1 Irrigation ❑Remedial
<br /> - - - �'.~1 y� I �Elevator n Dewatering ',�
<br /> '�'� E T r } CASING MATERIAL Drive Shoe? [_Yes �No HOLE DIAM.
<br /> I � _'Steel I`Threaded ❑Welded
<br /> 'h Mile '' —'Plastic '
<br /> - - -- 1 �� CASING. ���`
<br /> _ g 4 1 , Diameter Weight Specifications
<br /> j..�
<br /> �i M;ie� �_in.to__jj�fl. �Ibs./ft. __ _�in.to���
<br /> � PROPERTY OWNER'S NAME/COMPANY NAME in.to fL Ibs./ft. in,to ft.
<br /> �2` Tw� L, in.to ft. Ibs./ft. in.to ft.
<br /> .tEl7 JtJCJ I� � OPEN HOLE
<br /> Property owner's mailing address if difterent than well location address indicated above. SCREEN _
<br /> � Make ��t'�]$Q[i From _ft. To ft.
<br /> TYPe ��.���1deS e�1 Diam.��» --
<br /> rcrrc � �'r�—
<br /> SIoUGauze h1 n Length
<br /> •
<br /> Set between ft.and ft. FITTINGS �
<br /> STATIC WATER L
<br /> Measured from
<br /> --—....---_-__— .:
<br /> __�_______tt.��' elow ❑Above land surface Date measured 12�31�9 '
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPWG LEVEL(below land surface)
<br /> 93 ft.after 2 hrs.pumping Z� g.p m.
<br /> Well/boring owner's mailing address if different than property owner's address indica�ed above. WELLHEAD COMPLETION
<br /> [�Pitless/adapter manufacturer — Model
<br /> a[ �S`S�l-��.�-�"i'"
<br /> ���Casing Protection � I„�-2 in.above grade
<br /> �At-grade(Environmental Well and Boring ONLY)
<br /> GROUTING INFORMATION
<br /> Well grouted ,�CYes �J No
<br /> Grout materials ��=J Neat cement �'Bentonite L]Concrete !�Other_
<br /> From�To�ft. _� U Yds. [�Bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From�__To_�.ft.�},�$���'�s. ❑Bags
<br /> MATERIAL From To ft.
<br /> ❑Yds. ❑Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> �0 ��f A ����`�S. .�L� Q � � t=....� feet -,.3.> direction F ���-� .
<br /> ..,-:.tS,�.
<br /> Well disinfected upon completion? �'Yes ❑No .;�,_, �„�,�.,,;..._,;$
<br /> G�.B e��.C1Ed (f�s� et PUMP
<br /> ❑Not installed Date installed �;�-�'�
<br /> C�a •� �r8 ��� 'K, 7S Manufacturer's name
<br /> "`-- ..
<br /> ,�`=,� /� t Model Number HP�Volts � �'~
<br /> ` ���� �� � l7�1'� 7" j�O Length of drop pipe �i U ft. Capacity g.p.m.
<br /> Type:�� ubmersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑
<br /> ABAN ONED WELLS �
<br /> Does property have any not in use and not sealed well(s)? �_.J Yes ��- No
<br /> VARIANCE
<br /> Was a variance granted(rom the MDH for this well? U 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�f-rID'tigP:o ine�i jn th��Ro�����th�be�s�t.f m�no�'w:edge�. �ivisic� of
<br /> Use a second sheet,if needed. � S j j i VS) .
<br /> ' REMARKS,ELEVATION,SOURCE OF DATA,etc. !�j .7todola i�ell Dc3llirt� C�,. ��..'• 1��1
<br /> Licensee Business Name Lic.or Reg.No.
<br /> � � ,�� � :� �,
<br /> :�
<br /> Re�re�entative Signature i Certified Rep.No. Date
<br /> LOCAL COPY
<br /> 770046 J� ��'I�
<br /> Name of Driller
<br /> �C 140-0020 HE-01205-11(Rev.3/07)
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