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MINNESOTA UNIQUE WELL WELL OR.BO�iING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. Counfy Name WELL AND BORING CONSTRUCTION RECORD g 2 3 4 3� � Mipnesota Statutes,Chapter 103I i , Township Na Township No. Range No. Section No. Fraction WELUBORING DEPTH(compieted) DATE WORK COMPLETED £ , i�s n �a�o-�6 � GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD ' Latitude Longitude ❑Cable Tool ❑Driven , ❑Auger �otary ,. House Number,Street Name,Ciry,and ZIP Code of Well Location []Other .`�-r 122(1 �cacketts cV��t i��i��{�»5539I DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section gri X" Sketch map of well/boring location. t�.[tt��te From fl.To ft. Showing property lines, � roads,buildings,and direction. USE ' N �Domestic ❑Monitoring ❑Heating/Cooling __j_____j___ __�__ ___;__ �,,,� � ❑Noncommunity PWS �Environ.Bore Hole ❑Industry/Commercial � �y S ❑Community PWS []Irrigation ❑Remedial --�-----�------=-- ---=-- �,,� Elevato - Dewateri '] '�( ❑ � U �9 � w e ` �, - CASWG MATERIAL D r i v e S h o e? ❑Y e s �— o HOLE DIAM. � T � : --;--- --;-----�-----:-- � ❑Steel !]Threaded ❑Welded 'h nniie � lastic -' ------ ------ ---�-- ---:-- 1 � � C �AS�NG S � Diameter Weight Specifications �i Mi�e--{ �in.To 154 ft. Ibs./ft. $_in.To_��. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. �in.To I7(�. Fielch For�an in To ft. Ibs./ft in.To ft. Property owner's mailing address if different than well location address indicated above. L SCREEN OPEN HOLE fi()2b P31Is�ury Ave S Make Qlin�� From ft To ft. �1ir�nea lis MN 55419 TYPe stainless stee2 Diam. � � SIoVGauze �S Length �,t► f� Set between ft.and it. FITTINGS STATIC WATER LEVEL Measured from * 4� ft elow ❑Above land surface Date measured ��l WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) L 5� ft.after 2 hrs.pumping )� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �Pitless/adapter manufacturer Whit�water Model ❑Casing protection �'12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT WFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material tX(]�Q21�.t L From�To__��ft. _�_ ❑Yds. �Bags Material��'�llt.n.1.--�tCC'L---iiJ--To j rlji ft. �Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Drivencasingseal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION ��112 `�ST� p��! $C}lt � 1� /.i „1 feet �� direction � 1--•�'-'�-"t� 1 Well disinfected upon completion? es ❑No Cl$yI S8t1� �;L'Aj�' f��L�it 2$ �iO PUMP / ❑Not installed Date installed Zl1-17-16 �189e1�C1$� �CS� I}l��1�11 `!`� �3 Manutacturer's name Schaefer Model Number HP i�� Volts �� s�ndy clay gray medium 63 13$ Length of drop pipe ft. Capacity g.p.m „u' y�� r,t �qp �?O Type:�Submersible �J LS.Turbine ❑Reciprocating �Jet ❑ 3f2llU u i .�a ! ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes o VARIANCE Was a variance granted from the MDH for this well? ❑Yes o TN# WELL CONTFACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. - The information contained in this report is true ro the best of my knowledge. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. _ Don Staiola We21 T�c�illing Co,. Ic�. 1691 Licensee Business Name Lic.or Reg.No. c....--" �'� ' 32-21-16 ifi �p SeMa �Si u '�� Certified Rep.No. Date Rt>b Sttx101a .. � L�Ci/�L Ci�PY '� . . � V L��7 ��J� Name of Driller . �� ID#52603 HE-01205-15(Rev.8/13) ::ii