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MINNESOTA UN/QUE WELL
<br /> WELt OR BOR NG LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
<br /> ;: CountyName WELL AND BORING RECORD . �, �} �_, ,�� ,.�
<br /> TT������n Minnesota Statutes,Chapter 1037 � � � r,.j' � �
<br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
<br /> ntCJxlo 11€3 23 ?.7 ,rSt� ��F; Ss^� r n r•_�
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds
<br /> Longitude degrees minutes seconds �Cable Tool ❑Driven
<br /> ❑Auger �otary
<br /> House Number,Street Name,City,and ZIP Code ot Well Location ❑Other
<br /> { �rJ�� '`Tncth Far� ?t�., �JCOT�O 55356 DRILLING FLUID WELL HYDROFRACTURED? (.._I Yes . o
<br /> Show exact location of well/boring i ectio id with"X" Sketch map of well/boring location. ?�'T1ttIIl�tQ From ft.To ft.
<br /> Showing properry lines, ---
<br /> N roads,buildings,and direction. USE Domestic ''^'Monitorin
<br /> � , 9 [�Heating/Cooling
<br /> � , . , i'.
<br /> . __L____,___ __:__ ___:_ �,� � ' ❑Noncommunity PWS I�Environ.Bore Hole �Industry/Commercial �
<br /> - ,,Communiry PWS ❑Irrigation �I Remedial
<br /> ; I I ; I ^
<br /> --'----;-- ---;-- ---`-- U Elevator ❑Dewatering ❑_
<br /> � `N ; ; ; ; E T ASIN Shoe� �No OLE DIAM.
<br /> ��;:, --+-- --�--- --�-- --,-- t. MATERIA ve . . -
<br /> C G L Dri �'Ves , H
<br /> - I f �'��teel �Threaded [_]Welded
<br /> a � � , , Mile ._ ,.
<br /> / �
<br /> , , , , � �� �.1 Plastic --_ ��.'
<br /> �' --;--- --�-- --�----�- t� CASING '
<br /> S � Diameter Weight Specifications
<br /> ��Miie-�{ �__in.To_��_ft. Ibs./ft. �__in.To�ft
<br /> PROPERTY OWNER'S NAMEiCOMPANY NAME in.To ft. ._ Ibs./ft. �5.- in.To��r�ft
<br /> ci-�
<br /> ��C�+�rrl p�C�tj�g in.To ft. IbsJft. in.To ft
<br /> SCREEN OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated above. y'
<br /> Make From ft. To ft.
<br /> 7yPe .�'sta Il �gS .:it� Diam. �n �.
<br /> SIoUGauze .��_� _Length �{� + cF�
<br /> Set between�[t�ft.and it RTTINGS �� „ -
<br /> STATIC WATER LEVEL
<br /> Measured from
<br /> C?� _ft.�Below ❑Above land surface Date measured
<br /> - WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> / ft.after hrs.pumping g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
<br /> Pitless/adapter manufacturer �������� Model
<br /> ❑Casing protection �12 in.above grade
<br /> ❑Ahgrade [��Well House I�'�Hand Pump �
<br /> GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
<br /> Material ��tQE1j.C'�Fro+�m' � To ?�1 ft. � U Yds. �Bags
<br /> - Material__�r�tUral .t�c6�f.. S�To ��#t ft. _ ❑Yds. ❑Bags
<br /> v
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Matenal From_____To ft ❑Yds. ❑Bags
<br />. MATERIAL Driven casing seal From To _Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> . tt��30�1 hlBC?' �c�fr ^� 2 � � y
<br /> _ feet ___ 1 direction ry
<br /> � Well disinfected u on com letion? ` �
<br /> 1 c P P �1'es ❑No .ti.3..c�.�.a,.�i..
<br /> � C1.'?� hCO.�Tl ��������]I!1 � �V PUMP �
<br /> j�Not installed Date installed ��..���';
<br /> clay �,c�y rpediwn i5 �2 " ., -
<br /> Manutacturer's name
<br /> G�� Yns� ��t� �1 t t 5 Model Number HP � Volts 7
<br /> 1 1 t Lt
<br /> Length of drop pipe 1 7G ft. Capacity g.p.m
<br /> t } -T.
<br /> tj[$y'Q!}. ���j���':t+l �,aCCI lia �-�'j� Type�'Submersible ❑LS.Turbine ❑Reciprocating ❑Jet [�
<br /> ABANDONED WELLS
<br /> Does property have any not in use and not sealed well(s)? [j Yes o
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? �]Yes o TN#
<br /> WELL CONTRACTOR CERTIFICATION
<br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. ,
<br /> The information contained in this report is irue to the best ot my knowledge.
<br /> Use a second sheet,if needed.
<br /> �� REMARKS,ELEVATION,SOURCE OF DATA,etc. �il �C���$ ��Tell �ril.t�t��; Co., Inc• �C77� .
<br /> Licensee Business Name Lic.or Reg.No.
<br /> ,: ;-�' ' 1�'-31-13
<br /> Q�rtifie8 Represenrative Signature Certified Rep.No. Date
<br /> iOCAL COPY ` `-� �., `, 6� PQf' �`CCX�I018
<br /> f � �_ Name of Driller
<br /> IC 740-0020 � � HE-01205-14(Rev.S/12)
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