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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name t, WELL AND BORING RECORD <br /> Wepi('(�C..9 t A Minnesota Statutes Chapter 1031 610 4 5 2 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> OROh4O In t, 073 vi -2 'SF/.00 W 3 O5- a. <br /> House Number,Street Name,City,0and Zip Code of Well L cation or Fire Number DRILLING METHOD - �!�� <br /> 365 Ott[] ! O�'�4A ❑Cable Tool ❑ Driven 0 Dug <br /> ��Ll in <br /> ❑ Auger otary ❑Jetted <br /> Show exact location of well in section grid with.r. Sketch map of well location. ❑ <br /> 0 Showing property lines, <br /> roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES LO <br /> N <br /> s R�'t1.,/� Ai <br /> p <br /> + + + R7F��1O �7{ito FROM ft.to ft. <br /> i i tff� 7- USE ❑ Domestic 0 Monitoring 0 Heating/Cooling <br /> -- - <br /> 0 Community ❑ Indust PWS /Commercial <br /> , , .-" irrigation Industry/Commercial+- -+-- <br /> w + + E T 0 Test Well ❑ Noncommunity PWS 0 Remedial <br /> i 1. --r-- I ❑ Dewatering 0 <br /> 1 /�w. CAilifatrSING " Drive Shoe? 0 Yes lIC io HOLE DIAM. <br /> i i .'-'4111.61:1 <br /> _ .kSeel ❑Threaded lrelded <br /> 1 ❑ Plastic ❑ <br /> S <br /> F__-,Milo--.-I <br /> Pe/4A • CASING DIAMETER WEIGHT <br /> PROPERTY OWNERS NAME (a in.to 2.7.0 ft. <br /> (p� OR <br /> lbs./ft. /bin.to t. <br /> V14 OF OROPi© in.to ft. Ibsfft. _in.to ft. <br /> Property owner's mailing(� address If different than well location address indicated above. In.to ft. lbs./ft. _in.to_ft. <br /> P.0. •.�+0 t SCREEN OPEN HOLE ��y <br /> C NISM �VZIPF.01:241 <br /> Make from a.4 0 ft, CJS ft. <br /> ��G , _1 <br /> Type Diem. <br /> VO9� 1M <br /> N 01 N r SS 3SCo Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME S 7 ft.OKbek)w 0 above land surface Date measured S 18-90 <br /> C.ry of OHO PUMPING EL(below land surface) <br /> Well owner's mailing address if different than property owner's Address indicated above. i ft. after $ hrs.pumping : /s0 g.p.m. <br /> P• , <br /> WELL HEAD COMPLETION <br /> Cl Pitless adapterrpanpfacturer Model <br /> ❑ Cesing°Protection *12In..abovegrade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? )6es 0 No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material eat cement 0 Benton 0 Concrete High Solids Bentonit <br /> MATERIAL ,t <br /> to /qo ft. 1 0 yds. bags <br /> from to ft. ❑ yds, 0 rags <br /> a kl 60 V C. sok* O to from to___0_ft. __OWL ❑ yds. bags <br /> NEAREST/+O5 SOURCE OFCO AMINAT�IONG wEWA 70 HO feet � <br /> direction PQ1141:4 type <br /> \ Well disinfected upon completion?. "%i'es 0 No <br /> •jti41 6M t 50l() 15O PUMP <br /> t ❑ Not installed Date installed <br /> S 15rhd(JRdck <br /> Bd04611,4464 Mtfit1\vM t St} 2.08 Manufacturers name G LLQ!r4 a FOS <br /> _t � Model number HP 10 Volts Lk° <br /> L.%MUGS 1O 4lL 1/AIfV 14.0.41 203 ZZO Length of drop pipe jlh ft. Capacity /35- g.p.m. <br /> LIME SR c�S sok I i�U(I4- `w Jv F� '2 S4 Type: ONSubmersible 0 L.S.Turbine ❑ Reciprocating 0 Jet 0 <br /> t ABANDONED WELLS <br /> t 2 Does property have any not In use and not sealed well(s)? 0 Yes gleNo <br /> Li N44%1-0`f &fF �L�IaRN_r J <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? 0 Yes lieNo <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 port is true to the best of my knowledge. <br /> Business Name Lk.or Reg.No. <br /> �' I <br /> Authorized Repro; tative Signature Date <br /> I�C.N RtitiVvh�' / <br /> IMPORTANT FILE WITH PROPERTY PAPERS 610 4 5 2 Name of Driller Date <br /> WELL OWNER COPY HE-01205-06(Rev.9/96) <br />