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<br /> WELL�OCATfON MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUEWELL NO.
<br /> County Name WELL AND BORING RECORD � ,� ...
<br /> � (`�
<br /> � i,�,! Minnesota Statutes, Chapter 1037 �, �? !.; � ,1
<br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed �
<br /> dra�v 118 23 32 �� �� �� 18€3 ry 11-2I�
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds
<br /> Longitude degrees minutes seconds I.�Cable Tool �Driven � ���Dug
<br /> J Auger �Rotary �Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number � �-�
<br /> .7V'!V d�{,.�i !'lili Ad OrOIIO 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o
<br /> Show exact location of well in section grid with"X". Sketch map of w II location. ��e'�
<br /> �howir�y pro erty Iines, FROM_ }t.TO ft.
<br /> N �ads a buildings USE —
<br /> t,►1 ��vff Lj Monitoring ��Heating/Cooling
<br /> � � � � �Domestic �Environ.Bore Hole �._,Industry/Commercial
<br /> -'-- --'-----`----`--
<br /> v Noncommunity PWS ❑Irrigation . �,Remedial
<br /> � L Community PWS ]Dewatering �_
<br /> --'----i--- --`-- --`-- -
<br /> W i ; ; i E� ASING Drive Shoe? ❑Yes �No OLE DIAM.
<br /> �� � ' ' ��'le GA[/.;' j� • t� R. � �Steel ����Threaded �Welded
<br /> --�--- --�--- --�-- ' I H
<br /> '/Mile 18StiC �
<br /> __;_____,;_""'�_____;__
<br /> 1 �� CASING DIAMETER WEIGHT
<br /> , , S , , �'`il q 1
<br /> �1 Mile—� � �in.to__._�ft. G��l Ibs./ft. �in.to�ft.
<br /> ! �p�
<br /> ._in.to ft _ Ibs./ft. �in.tojQ�Qft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft.
<br /> Bob Fitc�h Constnuticm SCREEN OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated above. Make ���� }� FROM ft. TO ft.
<br /> 11725 54Lh AVe N Type��-u�'�"�/�'�+ Diam.
<br /> _ ._ —. .._�—A ___
<br /> P� tL � ttLLq SIoUGauze_ __.,,,_ •41V Len th '�'
<br /> � �I� JJ�4ff4 9 N �
<br /> Set between___���_ft.and��fl. FITTINGS
<br /> STATIC WATER LEVEL *
<br /> 95 ft below �.J above land surface Date measured �a_���
<br /> PUMPING LEVEL(be ow land surface)
<br /> WELL OWNER'S NAME/COMPANY NAME
<br /> 1� ft.after 'L hrs.pumping 2S g.p.m.
<br /> W L HEAD COMPLETION -�-d t�t�r
<br /> Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer__�111 Model
<br /> ;Casing Protection �12 in.above grade
<br /> ���j Abgrade(Environmental Wells and Boring ONLY) -
<br /> GROUTING INFORMATION �
<br /> Well grouted �Yes ❑No
<br /> Grout material . _Neat cement C-Bentonite I��Concrete High Solids Bentonite
<br /> from_�_.to�,__ft _ �yds. �bags
<br /> from__�to�,,�_fl. ����j�, [ �bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. �yds I._�bags
<br /> MATERIAL
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION �
<br /> Cl$ ��� �i� 0 16 �....� feet � l./_/ direction Ji._,__,.'-'-1�•_• tyPe
<br /> Well disinfected upon completion Yes []No
<br /> C18 CS SO.gL �E� �2O PUMP
<br /> ❑Not installed Date installed__ �� �
<br /> �Y.! $ $��� �ry� ��� Manufacturer's name
<br /> ii�i[A1 bl/ q
<br /> Model number _ ____HP�Volts L.�
<br /> C � �f� i"jG '175 Length of drop pipe 146 ft. Capacity g.p.m.
<br /> Type: Submersible � '��LS.Turbine L,Reciprocating �Jet ��
<br /> � b�� �ft 1'l� 1W ABANDONED WELLS
<br /> Does properry have any not in use and not sealed well(s) �Yes o
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? I �,Yes . No TNk
<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 � �=�O'+ �� ��� ^�i' *�• ����
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. iX� v{,T y
<br /> Licensee Business Name Lic.or Reg.No.
<br /> � r""
<br /> � ,.-� '�, _ - 2�17-11.7
<br /> Aut oriz epresentative Signatur�� Date
<br /> � i RJil�
<br /> LOCAL COPY NameolDriller
<br /> 71 � � � 3
<br /> HE-01205-OS(Rev.5/02)
<br /> IC 140-0020
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