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MINNESOTA UNIQUE WELL <br /> WELUBORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> ° Counry Name RECEIVE[�ELL AND BORING RECORD �7 4 3 4 4 8 <br /> ' Minnesota Statutes,Chapter 103I <br /> Hennepin <br /> Township Name Township No. Range No. tion o. F WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> UrOi10 117 'L3 O8 ��: v< v< 1C?O n 1—ZZ—Q7 <br /> GPS ���0 DRILLING METHOD <br /> LOCATION: Latitude__ degrees te ___. s . _ <br /> Longitude degrees minutes seconds___ �_l Cable Tool '� I Driven ��-Dug <br /> �° ' L.Auger �Rotary I 1 Jetted <br /> '�� House Number,Street Name,Ciry,and Zip Code of Well Location or Fire Number - <br /> 1535 Minnie Ave, OL�OTIO 553 4 DRILLINGFLUID WELLHYDROFRACTURED? 7Yes ' No <br /> �'. Show exact location of well/boring in section grid with"X." Sketch map of II location. �8�e C From ft.To_ ____ R '�� <br /> �� Showing pr erty lines, <br /> N �V buil.ings, USE _Domestic �_!Monitoring u Heating/Cooling <br /> a d tion. `-Noncommunity PWS J Environ.Bore Hole . �Industry/Commercial <br /> � --'�"- "�J-�- --`-- ---�-- _Community PWS J Irrigation '�_Remedial <br /> ❑Elevator `�Dewatering <br /> -------- --- ------ --- -- f CASING MATERIAL Drive Shoe? I.�Yes No HOLE DIAM. <br /> --'--- --�--- ---`-- ---`- yN'�astic LThreaded . Welded <br /> w ET ( � , <br /> � i <br /> Vz Mile <br /> " ' ; ' ! CASING <br /> --.--- --�--------- ---=- 1 � <br /> � Diameter Weight Specifications <br /> ; S ' <br /> � 4 92 2.01 ast� 8 30 <br /> �—1 Mile� in.to ft. Ibs./ft. -��4��-in.to���(�ft. <br /> in.to ft. Ibs./ft. "• in.t0'"" ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. �� in.to ft. <br /> Lisa t'lSLIWSCL�L� SCREENT OPENHOLE <br /> Property owner's mailing address if different than well location address indicated above. Make J_Qhn s�� _ From ft To_, ft. <br /> 8a�� a$ abone TYPe �.LLl,LI1.�PA1l4 !X�'� . - Diam. ZN <br /> � ----�---- <br /> ', Slot/Gauze_ _. ���. Length �! ,�, ��__ <br /> Set between ft.and it. FITTINGS # Q <br /> STATIC W�LEVEL �'����I <br /> ft.�Below , .Above land surface Date measured_____ <br /> PUMPING j.��L(below land surfacej � �� <br /> WELUBORING OWNER'S NAME/COMPANY NAME <br /> ___._ �l ft.after �'� hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION <br /> Well/boring owner's mailing address if different ihan property owner's address indicated above. �piUess Adapter Manufacturer _'^�`Tllodel__ <br /> '��Casing Protection_ __ �92 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) � <br /> Z GROUTING INFORMATION <br /> Well grouted? �Yes ! I No y <br /> Grout ma�erials . �Neat ceme��l"Bentonite q�6pncrete I I Other�____. ___ <br /> From To_�Qa��ft. �'�[�Yds r]���7 gs <br /> From�To �"tt. n u af�}Yd���.'��Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_ To ft. '�. !Yds. ...Bags <br /> MATERIAL <br /> ? NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay/sand brown soft � I$ --- �� �eet � direction � ���-��� <br /> Well disinfected upon completion? ��. es CI No ',�..�� �; <br /> CISy F;CH}� SOfC iS US PUMP �-t�.3 G�O <br /> I I Not installed Date installed <br /> � Manufacturer's name `� �'�-�" �-^' �" <br /> � sand brsy soft 85 I00 J��� �o�ts ��a <br /> Model Number HP <br /> Length of drop pipe CLr� _. ft. Capacity_ _ g.p.m. <br /> Type:'� ubmersible '.�1�.S.Turbine �. �.Reciprocating i.'Jet i��� �� <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? i.I Yes y*No + <br /> VARIANCE <br /> Was a variance granted from the MDH for ihis 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 ihe best of my knowledge. <br /> Useasecondsheet,i/needed. �n �'�Q(��la W�,fIZ Drilling Co, s .71��• �6 L i; <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> — - . _ _ _ —__9-- —. <br /> Licensee Business Name Lic.or Re No. <br /> _ :.� {.3-�'� <br /> : A o epresentative 5ignarure��.- Date i� <br /> Ch�ck Mooce <br /> ... -.__ _. ....__- ._ -- ...... �f <br /> LOCAL COPY 7 4 3 4 4 8 Name of o�iuer <br /> HE-01205-09(Rev.9/05) <br /> IC 140-0020 <br />