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,t .-i _ <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD ( /; <br /> �� � Minnesota Statutes,Chapter f037 I' � ��+ � � <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> 4cono 117 23 10 ,� �� �� 318 ,` 5-24-05 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees minutes seconds L�Cable Tool !�Driven ' Dug <br /> � Auger �Rotary ❑Jetted <br /> House Number,Street Name,Ciry,and Zip Code o(Well Location or Fire Number i �� . <br /> 214E3 North Shore Dr �C�� 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o <br /> Show ezact location of well in section grid with"X". Sket h map o well loca�ion. �t��. FROM ft.TO tt. <br /> howing roper y i es, <br /> N road and buii ngs USE - Monitorin <br /> �l L� 9 ❑Heating/Cooling <br /> � __j_____j___ __�___ �_ u, �'Domestic [�_'Environ.Bore Hole ❑Industry/Commercial <br /> � �� _....,.._ �'.Noncommunity PWS U Irrigation ❑Remedial <br /> �� ; ; ; ; p y �I Community PWS []Dewatering :���'�. <br /> � --'-----�-----`-- -- -- <br /> � <br /> ` W ; i ; ; E� + ASING Drive Shoe? �Yes �J No OLE DIAM. <br /> � C I H • <br /> � ______ � � } �Steel ,�Threaded _'�.Welded ; <br /> 7 Mile t I^]Plastic ❑ <br /> �, ' ' � � 1 CASING DIAMETER WEIGHT ' <br /> � � S � � <br /> �—i M��e� :f./ .� 3- __�.�_._--�� �±.��.��.. . —�in.to _..�ft ZZ IbsJR �in.to�. <br /> in.ro .._—__ fc _.__ IbsJft _�in.to�,�y. <br /> � PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. ���p to�y�p. <br /> Arter/Cheri Kr�er SCREEN OPEN HOLEs�n� o <br /> Propert�owner's mailing address if different than well location address indicated above. Make —' " ��o <br /> FROM ft. TO ft. <br /> � 88 g��s Type Diam. _ <br /> SIoUGauze Length <br /> - Set between ft.and it. FITTINGS <br /> - STATIC WATER LEVEL <br /> 7� ft,�below �above land surface Date measured_��2�}�5 <br /> PUMPING LEVEL(below land surface) <br /> � WELL OWNER'S NAME/COMPANY NAME <br /> _�__ft.after � hrs.pumping__. _g.p.m. <br /> WEL��16�D COMPLETION :'iA E <br /> Well owner's mailing address if different than property owners address indicated above. ��v <br /> �,,Pitless adapter manufacturer �1�1� �� �{�1ode1 <br /> ��Casing Protection `yd''12 in.above grade <br /> ��At-grade(Environmental Wells and Boring ONLY) r <br /> GROUTING INFORMATION <br /> Well grouted ,S�Yes �No <br /> Grout material :,J Neat cement [�Bentonite .Concrete�High Solids Bentonite <br /> from�to_�ft �_ ❑yds. �bags <br /> from�__to��ft. �,�j[�,1 ��.��bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. _yds. �bags } <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> J �.. �� <br /> .�[A! bt�,l �C� p �u feet �" direction '-._ '�-�-�'"�J'l'yp <br /> i f7 � <br /> Well disinfected upon completion .�Yes [__ No ���„�.,,f.,. <br /> � PUMP ` <br /> : cl �c zio `� <br /> t Not installed Date installed � "'�`v� - �V� <br /> ��' �1 �1 Q.�,�f �� �� �.}h Manufacturer's name_yr�J�.rYV��,.'�-'`�-i�""' ._ <br /> 1 1 LCli ,��1 ,� <br /> Model number HP__�Volts :�� <br /> j„`�,$ � � 'l z� Length of drop pipe ���V ft. Capacity g.p.m. <br /> gravellsl�leJ �«/ Type: ubmersible []LS Turbine `�Reciprocating ]Jet ;� <br /> .��SCOIIe �UJ.iCtt f)COM�] � yt � � ABANdONED WELLS € <br /> Does property have any not in use and not sealed well(s) �]Yes [.�,'No <br /> �31D�.�tOI� � � !L �� VARIANCE <br /> Was a variance granted from the MDH for this well? L]Yes�No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in acwrdance 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,il needed " <br /> " REMARKS,ELEVATION,SOURCE OF DATA,etc. �j� ,,St,�ol�, W��.1 Drillinsa W�� 111C� �Z�7L <br /> Licensee Busin ss me Lic.or Reg.No. <br /> / � <br /> � /, � /j, t�JV <br /> E�✓ <br /> o'e epresentative�'i ature � � Date <br /> ... '��`���� ��� <br /> LOCAL COPY 7 2 6 4 0 3 Name ol Driller -- <br /> HE-01205-OB(Rev.5/02) <br /> : IC 140-0020 ^ <br />