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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1 WATER WELL RECORD M/NNESOTq UN/pUE WELL NO. ���s�O <br /> Count. �e j�, <br /> /o'Wafe�Sample <br /> ..tt r',1�?y� Minnesofa Sfafrles 156A.0/�.08 � <br /> Township. , ownship Number Range Number Section No. Fraction 4.WELL DEPTH(mmpletedl Date of Completion <br /> f?C�.�r��s 1�! � �� W lri at� '' SF''' [+� ��:`� u. 11—�—�i� <br /> Numer�al Street Address and City of Well Loca�po or Distance from Road Intersection. 5.DRILLING METHOD <br /> �/j l"�� ❑CableTool ❑Reverse ❑Driven ❑p� <br /> 1� J�:: . �t�UiF.:1i21� l..�i' �it� �3�"(3;1K:s! �";:1,Iit1. e <br /> ct lacation d well in section � with"X." Sketch map of well location. ❑HollowNod ❑Air ❑Bored p <br /> �� � <br /> � � � _i _i_ Addilion Name �t.. '->��� �I Rotary Oletted O Power'AuBer <br /> �_ , � ' € 6.DRILLING FLUID <br /> ' ' ' t 4—d <br /> '-�- -�- �- �- Block Number 7. USE <br /> W � � � E <br /> i <br /> _i_ _y_ _� __ ,ei(7 Domestic O Monitoring ❑Heat Pump <br /> � � f mi. �t Number .��i.,�. , ..J_�v ,i-.t . ❑Urigation ��Public O Industry <br /> ' � � � � --�� ❑Test Well {]Municipal O Canmercial <br /> --�- �- - -r- ❑AirConditioning ❑ <br /> �—l mile—'a 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME <br /> Mailing Address if different than property address HEIGHT:Above/Below <br /> f�[Black �j Threaded <br /> � �,ti�.l�� ��,p.��. indicated above Sur(ace (t. <br /> t 't��,,.� ❑Galv. <br /> � �ti.i .�ac+}���L14.Ji�� .��<_?Xi�1�A[sy ❑Welded Drive Shce? Yes�No_ <br /> YW1.�`1 a7�t::)�'7:3 �1[f6��:lSwfE:"L OPlastic ❑ (� 1 i� <br /> .��t?.L'� 3.' 'i; ` . <br /> r <br /> -y3� ,.�.. ., `". in.to �-��� fL Weight IbsJ(t. �n. to�..�.,t,_1�[. <br /> 3. FORMATION LOG COLOR ORMATtON FROM TO in.to ft. Weight Ibslft. —�n. to�t. <br /> in.to (L Weight Ibs./ft. �n. to-1[. <br /> t 9.SCREEN Or�open hole <br /> Make <br /> �U�,�„���� trom ft.to. ft. <br /> ']'ype ..�7��.i.Z.t�11L..�:.i �.ft'_C�E?t Diam. ,4,N <br /> SIoVGauze �,;y Length -�_ <br /> FI'P9'[NGS: <br /> - Set between '�P�ft.and `��(t. <br /> 10. STAT[C WATER LEVEL <br /> � :.t�. �;r f[�below ❑above Date Measured t <br /> ����H��� <br /> � land surface <br /> I1.PUMPING LEVEL(below land surface) <br /> '�c'� F- ( <br /> �i+ � ft.after hrs.pumping �•+ g.p.m. ' <br /> (t.atter hrs.pumping g.p.m. <br /> 12.HEAD WELL COMPLETION <br /> Pidess ada ter manufacturer �++s- t�7 Model <br /> �ip P ��rtr�E° rv"K1�P3— — <br /> ❑Basement ottset jp At least 12"above ground <br /> ❑Plastic casing protection <br /> 1_ <br /> 13.WELLGROUTED? �Yes ❑No <br /> '� ❑NeatCement ❑Bentonite �h�.=t%"�tr'•�� p�+��ic3"f11 __ � <br /> �.. Grout material from ro ft.cu.yds.__ .:�:,.'� <br /> _ �. <br /> �..:.. �-- � <br /> I4. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction �y� <br /> 'i� <br /> Well disinfected upon completion? �Yes ❑No �+��� <br /> 15. PUMP <br /> J <br /> Date installed ��.'��t.�.`�� ❑Nol installtd � <br /> Manufacturer's name ��i`"1,]��1, — <br /> Madel num6er HP � Volts�a��} <br /> Length o(drop pipe�f�� ft. Capacity �S g.p.m. <br /> Material of drop pipe � ��jf{u (�.f�ty �-} <br /> :� <br /> Type:�]Submersible ❑L.S.Turbine L]Reciprocating <br /> ❑Jet ❑Centrifugal L7 _ <br /> l6. ABANDONED WELIS <br /> Unused well on property? ❑Yes �No <br /> Use a sxond sheet,ij needed P�ealed O Permanent ❑ Temporary ❑ Not sealed <br /> l7.REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> t8.WATER WELLCONTRACTOR CERT[FICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowltdge and belief. <br /> �r`N `.-'.�?�. 'Lr'q {ti�51.,L 1�2I1.�L.I 'NCs � � IIVC: L f�.7� <br /> Lirensee Business Nnme Liante No. <br /> Addres�t:_,t��� ��1 CiiZ{rt�,�7 i'�� i� M'�".�Cr"3� �t1_ - -.,�!`, <br /> Sign'Ti/�i^'�- �������Date�r'-�l-y�l <br /> Authortzed Re re ntatt �� <br /> t�` i�_ I�1tA'k;�i.:r, �acP I�—u—tl(! <br /> � NameoJDrtller - - <br /> 5/74 30M <br /> LOCAL COPY �� g 5 q � ;7e� <br /> HE-01205-03(Rev.9/88) ziE2 ip� <br />