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t y MINNESOTA UNIQUE WELL
<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. `
<br /> County Name WELL AND BORING RECORD (� :. .
<br /> � `_s ' E. F`.. �..
<br /> �tQn�� Minnesota Statutes,Chapter 1037 C)€,j � �'t �; �;
<br /> Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED�A�
<br /> �c��t� 11 g 23 ?.f� ��' �tt%r �;�,, ��3 tt 11-5-�'a� ? ��
<br /> GPS DRILLING METHOD �` �
<br /> Latitude degrees minutes seconds y �
<br /> LOCATION: ��Cable Tool � �Driven "
<br /> Longitude degrees minutes seconds _
<br /> :�Auger �j Rotary , �
<br /> House Number,Street Name,City,and ZIP Co e of Weil Location ❑Other ' � o
<br /> i.�.�r7 �I.l3A �f�W �C� Q QTI� 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑yeF
<br /> (`�G tJ
<br /> Show exact location of well/boring in section gr+d with"X"_ Sketch map of weil/boring location. jrj�t�s[ From___ '�TD✓� __ft.
<br /> �--� —� �-5howiqg properry lines,
<br /> N � roads,buildings,and direction. USE
<br /> � ! �Domestic ❑Monitoring _ Heating/Cooling
<br /> , , , , �
<br /> �. --J--- --J--- ---L-- ---%- �., 'L,,Noncommunity PWS ❑Environ.Bore Hole n Industry/Commercial
<br /> �.. I I I I � . .
<br /> ,
<br /> U --'----;--- ---`-----'— � mmu y WS iof n9 �I Remedial .
<br /> 1 � �Co nit P �Irrigaf
<br /> i
<br /> � ; � � � j — k
<br /> ' W � ; � E T `�� �e`� !, / CASWG MATERIALr rive Shoe? �,J Yes - No HOLE DIAM. i
<br /> �, --�--- ;----�-- ---%-- ' . / -_ D
<br /> � . — — '� � � �_]Steel ❑Threaded �_J we�ed
<br /> 'hMiie T � ;�.,Plastic ❑
<br /> 1 I �� 1 CASING
<br /> g ' -�� � Diameter Weight Specifications
<br /> ,�
<br /> /� r�
<br /> �1 Mile� _in.To 15 5 ft. __. Ibs./ft. .i in.To�,��tt
<br /> in.To ft. IbsJft. �'� in.To���
<br /> PROPERTY OWNER'S NAME/COMPANY NAME — �—
<br /> "Ss3 rk i'; *.�l i�.�.$?'1.S '`C�<�,n;� in.To ft. IbsJft. in.To ft
<br /> Property owner's mailing address if different than well location address indicated above.
<br /> SCREEN OPEN HOLE
<br /> ���' �x ,Lq Make Jah�son From ft. To ft.
<br /> ,2
<br /> �:�CE�14�Qr� �r.t 7����. Type giainles� RtQP� Diam.---+-
<br /> SbUGauze__ ��1=(j Length__��,+ /,�
<br /> Set between R.and ft. FITTINGS
<br /> STATIC WATER L � EL � � �
<br /> Measured fromtt C— /�
<br /> 1�� ft Below ❑Above land surface Date measured 11'�J'�1`t
<br /> WELL OWNER'S NAME/COMPANY NAME PUM�I�EVEL(below land surface) � �n
<br /> 1 V
<br /> ft.after hrs.pumping g.p.m.
<br /> � Well/boring owner's mailing address i�different than property owner's address indicated above. WELLHEAD COMPLETION `
<br /> �� �Pitless/adapter manufacturer�'���.CeG1r3C£�C ___ Model 3
<br /> i Casing protection �'12 in.above grade
<br /> . ❑At-grade ❑Well House ❑Hand Pump
<br /> GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings.or other)
<br /> Material �t1rAtt��'FFrom___�_To��ft. _�_ [�Yds. �Bags ,
<br /> Material�����7 �Fibr�i�_To__���_ft. ❑Yds. ❑Bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Matenal From To_ ft ❑Yds. ❑Bags
<br /> MATERIAL Dnven casing seal From To __Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> f11�.�CIlCt }�� C�{ :SAf� � � j '.� feet �-!...,� � .�.-,--�
<br /> ___ direction ���"��^�'�'Ai"'Ty�e
<br /> Well disinfected upon completion? Yes ❑No �`'
<br /> C�.t3y t�C(Y4�1!� f�'(�ILMI °+ ��i PUMP
<br /> ❑Not installed Date installed 1 i�l�"l�+`
<br /> ��`�� �� fi��� '�� �� Manutacturer'sname �c��aefer
<br /> Model Number HP 1i J Volts �-n�! �
<br /> cla�Isanc� �;r � r�c?itrn !+/� Z2� - ----
<br /> r,����Z 5� Length of drop pipe ��� ft. Capacity_ g.p.m
<br /> �,,.����y� C�,,;y ; ��r*� �,p n� Type: �Submersible ❑LS.Turbine ❑Reciprocating ❑Jet �]
<br /> '� n �._c?itr�� 1,. 13>
<br /> ABA ONED WELLS
<br /> c��� b'r��� ���'t 1 3r� �t c�� Does property have any not in use and not sealed well(s)? ❑Yes No
<br /> � � � VARIANCE �
<br /> � riCI3V�1 r11,�. C�rS�a a�j r./ �(�� Was a variance granted from the MDH for this well? [�J 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 the best of my knowledge.
<br /> Use a second sheet,if needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etC.
<br /> �'�nr� :"r�;'��.a weii rri.11in„ �:�,.Tnc. lfi�2
<br /> s Licensee Busine��lne �� !• Lic.or Reg.No.
<br /> !�'_.._
<br /> �� ,/
<br /> / ''' ��J 1-5-1.5
<br /> Certified Representative Signature Certified Aep.No. Date
<br /> , '.� �'._ ; ��, �Q.ti'} `1tC�iln�e'
<br /> i�GAL COPY � �_� � +�.,i Name of Driller
<br /> IC 140-0020 HE-01205-14(Rev.5n2)
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