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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BORINOG NO~'VELL <br /> WELL AN D BORING RECORD <br />cour~Name <br />}•~ Minnesota Statutes <br />Cha <br />ter 1037 ~ ~ ~ 5 6 5 <br />~~~~ ~ ~ , <br />p <br />Township Name Townsfiip No. Range No. Section No. Fraction WELL,BORING DEPTH (completed) DATE NlORK COMPLETED <br />Ana ~` ~ ,e~~~ 3~ ~3 35 ~~" 5~.. ~ ~-! ~, n to - / - U <br />GPS ~ <br />Latitude degrees minutes seconds <br />' OCATION: DRILLING METHOD <br /> <br />-? <br />U able Tool ^ Driven ~~ Dug <br />Longitude _ degrees __ minutes __ seconds ,{'~AUger [_~ Rotary ^ Jetted <br />ruse Number, Street Name, Ciry, and Zip Code of Well Location or Fire Number n <br />1 (~j Q ~ _-..1 ~,~~~~ ~ ~ ~ t`'~~ r ELf <br />LLL <br />:..... <br />[ <br />~ ~J~-% 7p~t~ j,~l~~ RILLING FLUID WELL HYDROFRACTURED? 1 i Yes ~ ~ o <br />ell/boring in section grid with "X ",{~ Sketch map of well boring location. <br />Show exact Iocatio <br />n <br />of <br />w <br />ro <br />lines <br />~ Showin <br />ert <br />~ 1` }~ ~ ~"~ ~ <br />F ' ' - <br />rom ~ _ fL To ft. <br />g p <br />p <br />y <br />, <br />\ <br />roads, buildings, and direction, . <br />N USE <br />^ Domestic ;Monitoring f i Heating/Cooling <br /> --; _ __;-_ __ ~_- __ ;-_ ` ) I ; ~ O ~ ~ j~ ~ <br />1`~J """i -' t V ^ Noncommunity PWS [ ] Environ. Bore Hole ^ IndustrylCommercial <br /> - L.j Community PWS ^ Irrigation ^ Remedial <br /> --=--- -- --- ---= -- --;-- I _ ` <br />~"' <br />~ <br />~ ^ Elevato j ewateri __ _ <br />r C <br />D <br />ng <br />W <br />--~-'- <br />---`-- <br />"--'-- E ~ \ <br />~ ~ ~ <br />1`„~ CASING MATERIAL <br />ri <br />Shoe? <br />(-~ Yes h o <br />^ S <br />l <br />' HOLE DIAM. <br /> '/ M <br />ile tee <br />Threaded ^ Welded <br />~ Pl2stic J <br /> -' 1 CASING <br />', S Diameter Weight Specifications <br /> in <br />to ~ ~ <br />~ <br />ft <br />Ib <br />(ft <br />I° `' ~- `~ nn <br />~ i <br />e <br />~ i Mile ----I . <br />, <br />_- <br />. _ <br />s. <br />. n. to <br />ft. <br />PROPEEiTY OWNER'S NAMEICOMPANY NAME in. to tt. Ibs.lft. _ _ in. to ft. <br />i , k n ~ <br />t in. t ft. lbs./ft. in. to It. <br />\ <br />Property owners mailing ad - ss i( different than well location address indicated above. SCREEN J ~ t try l O ~ OPEN HOLE <br />t 4 ~ ~ ~ ~~ `rJ ` / ~ 1 ~~ ~~ ~ ~~ yr ~ <br />~S T- Make---~~ _ <br />T <br />r Y ` From_ _ft. To ft. <br />='t <br />_ ` ~ -_ _ Diam. <br />ype <br />Slob'Gauze _ i ~' Length ~ U <br />Set between _ `~ tt. and ~ ~ tt. FITTINGS l ~ L--; -~1+ ~ i ~ v r i 1 <br /> STATIC WATER LEVEL Measured from- _][~, ~- <br />S~ <br />~ ' <br /> ~' <br />ft. i Below [j Above land surface Date measured +~+'' <br />t-` <br />WELL OWNER'S NAMElCOMPANY NAME PUMPING LEVEL (below land surface) <br />~~~ ~ '~\_' <br />L..`t ti,.~ __ft, after __ hrs. um in <br />P P 9-- ---g.P.m. <br />Well boring owner's mailing address if different than property owners address indicated above. WELLHEAD COMPLETION <br />_ - <br />~ zAXl -` <br />~ ~ Pitless/adapter manufa~,t„urd __ o el _____ <br />` O <br />~ <br />' <br />f <br />~ <br />- <br />- ~ <br />O _ <br />[ <br />Casing Protection `~ <br />! <br />2 in. afwve grade <br /> Al-grade (Environmental Well and Boring ONLY) <br /> GROUTING INFORMON ' <br /> Well grouted Yes ^ No <br /> Grout materials Neat cement ^8entonfte []Concrete ^ Other <br /> From C~t ~ To ~ ft. ~~ ^ Yds. Bags <br />GEOLOGICAL MATERIALS COLOR HARDNESS OF <br />MATERIAL FROM TO ~ From To ft. ^ Yds. ^ Bags <br /> From To ft. (1 Yds. ^ Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> f~ <br /> _teet _ direction }ype <br /> Well disinfected upon completion? ^ Yes No <br /> PUMP <br />Not installed Dale installed <br />Manufacturers name <br />Model Number HP Vofts <br />Length of drop pipe- __ ft. Capacity <br />Type: ^ Submersible ^ L.S. Turbine ^ Reciprocating (] Jet f_ I <br />ABANDONED WELLS <br />Does property have any not in use and not sealed well(s)? IJ Yes ~ No <br />VARIANCE <br />Use a second sheet, rf needed. <br />REMARKS, ELEVATION, SOURCE OF DATA, etc. <br />-~ 4 <br />',~.~1PORT;'.NT i=1LE'd~il`H PROPERTY PAPERS <br />v`J=LL Ci~VP.'=R COPY <br />Was a variance granted from the MDH ror this well? (~] 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 />~i' / <br />~ / ~ ~,( ;{ <br />__ / _ <br />Licensee Business~N/a'me,~` Lic. or Reg. No. <br />Certified Representative Signature Cerlitled Rep. No. Date <br />f <br />Name of Driller <br /> <br />Ic tao-oo20 <br />