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WELL LuCATION� MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD 5 4� 5 6 0 <br /> i.�,-��„,,�� Minnesota Statutes Chapter 1031 <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> C�T"UI1C1 G..� I �'tS t:.i .L% :S,Gw-lt(i�.'��; ��. � ..,p; <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Oriven ❑ Dug <br /> ��'4�' ��t'����X� �1VC' �C7�1(/ �'1 �JS,.. � ❑ Auger ,p Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> .t <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> i � � i i <br /> --r---I— —1 —1_ �"I'......_�._� <br /> � � <br /> i � � i �� __ ,USE ❑ Heating/Cooling <br /> ._�_ ___ _ �_ �Domestic ❑ Monitoring <br /> W � � � � E �� ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> ° ' T j�- ❑ Test Well ❑ Dewatering O Remedial <br /> _1_ _1_ ' ' I <br /> i _� __ � <br /> � � ' f•mi. ��r � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> ";- �' � -�' I x' ❑ Steel ❑ Threaded ❑ Welded <br /> 1 ,A Plastic ❑ <br /> �—1 milr� � <br /> r(,�� �) � <br /> •--�/�'I*�t/l./�I.lOCl1�l . <br /> � - CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME Ea 1 1+� �—,�1 ". ���� �( � <br /> '�,,�„,. in.to ft. Ibs./ft. � <br /> �U ���^�-� I�• in.to ft. Ibs./tt. <br /> Mailin address if different than ro ert address indicated above. in.to ft. Ibs./tt. -�-��4� <br /> 9 P P Y in.to ft. <br /> J���� '���� A�. �w�• SCREEN��� OPEN HOLE <br /> �.E..l Make _.,,,,,�t from ft.to ft. <br /> C,CY.?n iZ::�.�?]..f.�r� ��„ v_ �4L TYPe •C.�ZLl �'Sb .�C7C1 Diam� - <br /> SIoVGauze��l�_�� Length " <br /> Set between tt.and ft. FITTINGS: ' <br /> STATIC WATER LEVEL <br /> HARDNESS OF �_��t�.� <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ��1� tt. C��below ❑ above land surface Date measured '' <br /> i PUMPING LEVEL(below land suriace) <br /> elcy YE=13. .�3 �.'� !�{.j� 1 p� ft. after � hrs.pumping �4 g.p.m. <br /> t WELL HEAD COMPLETION �����r <br /> �.�lt�y ��� `;, ��:j� ��tl j,E] Pitless adapter manufacturer Model <br /> ❑ Casing Protection C}5.12 in.above grade <br /> Ci<7�7 B�C.'�WIl � i ic�� ��:{} GROUTING INFORMATION <br /> Well grouted? �L7 Yes ❑ No <br /> ��'y" � � �-�w -- Grout Material ❑ Neat cement C�[Bentonite <br /> �`�� '� �`"t' ��� from 0 �o .`��[; n. `� ❑ yds. C}`bags <br /> from to R. ❑ yds. ❑ baqs <br /> S�I�Y� C1G:y r G�' ��3 Br- � 1:3'�` 17C� r�om �o e. ❑ vds. ❑ eags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION . <br /> ��i.�bC� �1C;�.' � ► /!i� ����; ..,�-.�� l�,L.�;�a ;,'�� direction ^-.:>,'�` "" �/. type <br /> feet �.%�•�� <br /> Well disinfected upon completion? C]�Nes ❑ No <br /> PUMP <br /> 2—r9—y� <br /> ❑ Not installed Date installed [ <br /> Manufacturer's name E�T.Y(xJ�(Jr' �. <br /> Model number �_T__ HP ✓� � Volts �� <br /> Length of drop pipe � ft. Capacity 4 g.p.m. <br /> Pressure Tank Capacity ���r�c��i�� <br /> Type: C�5°.Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes O;(Vo <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,ilneeded �� ='�1r�J�� ��+ ��.��s �L�}.� T�. l�� l t <br /> REMARKS,ELEVATION,��f�.E OF�TA���� Licens eusiness Name Lic.or Reg.No. <br /> K 1 _�'/�=�_�wL��� t-�-5� <br /> � £ <br /> � Authonzed Represenfative Signature Date <br /> 'r°re�: I�ihy 2-8-9� <br /> � � NameolOriller Date <br /> LOCAL COPY 5 4 8 5 6 0 HE•01205-04(Rev.S/92) <br />