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WELL LOCA i ION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> Cou,.ty Name <br /> WELL AND BORING RECORD�':;I':i2:. 1. " Minnesota Statutes Chapter 103/ 5 8 0 5 19 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> -, ft. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> • ' I- "_4. t..-,y ti! . i. .r,.-•:-.. : ,i........ . ' ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger ❑ Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". map of well location. L( <br /> owing property lines, <br /> 1 t. roads and buildings. DRILLINGFLUID <br /> N \ <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i 1 ,❑ Domestic ❑ Community PWS <br /> _i - -I 1 ❑ Irrigation <br /> ❑ Industry/Commercial <br /> / ❑ Test Well ❑ Noncommunity PWS El Remedial <br /> w T IA Dewatering ❑ <br /> T- r- <br /> i! 7 � <br /> J N a G Drive Shoe? ❑ Yes g No HOLE DIAM. <br /> � �/p Mile l\ <br /> I- <br /> -1- <br /> - ❑ Steel ❑ Threaded ❑ Welded <br /> 1 `,_yam CI Plastic <br /> s <br /> Mile <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME ++ in.to ft. lbs./ft. in.to tt. <br /> . e'v-c"oi, I.)c,v ,...d.Or T.,ert t. 1 . E, <br /> in.to ft. lbs./ft. t, f iv.to I •ft. <br /> Property owner's mailing address if different than well location address indicated above. in.to_ ft. lbs./ft. in.to - ft. <br /> 1 . i .t.2.6 t lei?, `Lata R j•' SCREEN OPEN HOLE <br /> W _: i,a}22, MN.5'191 Make LTC',,:' ., from ft.to ft. <br /> c-a_. , <br /> Type 7: L s?a f Diem. <br /> Slot/Gauze Length <br /> Set between 1 i.'' '' ft.and I ( i" 'ft. FITTINGS: . <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME _ tt. ❑,below ❑ above land surface Date measured ' <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ft. after - hrs.pumping It g.p.m. <br /> WELL HEAD COMPLETION <br /> ❑ Pitless adapter manufacturer ' ' Model <br /> ❑ Casing Protection 0 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? 0 Yes 0 No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete 04-ligh Solids Bentonite <br /> MATERIAL from to ft. _ 0 yds. 0,bags <br /> from to ft. U yds. 0 bags <br /> SCA 1 11 Er(... • - i ' from to ft. 0 yds. 0 bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Gr-,••_.7e3 L! i ° , ,- ` feet j CY direction type <br /> Clay Well disinfected upon completion? ❑'Yes 0 No <br /> ;3i 1ty Clay Li..-,_.' :.re' - 1 t-';. PUMP <br /> 10Not installed Date installed _.- ` 4-9-11; <br /> z Manufacturer's name Sta--R1tE'- <br /> `_ <br /> 3 . <br /> Model number HP 1 Volts f.• t <br /> T <br /> Length of drop pipe f? o t ft. Capacity 1 tl g.p.m. <br /> Pressure Tank Capacity 8 0 Gallon Epoxy <br /> Type: ).Submersible 0 L.S.Turbine 0 Reciprocating 0 Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes ❑ No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? 0 Yes 0 14;1; <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> tr i. . 2i IA 1,-, S,i- L 1 t.f,J .Liat <br /> Licensee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature " Date <br /> /� (�C <br /> Name of Driller Date <br /> L OCAS, coOP` 5 8 0 5 x 9 HE-01205-05(Rev.1/95) <br />