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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL RECORD - 5 3 6 2 � 8 <br /> _�, ,�,�, �j,� Minnesota Statutes Chapter 1031 <br /> To�Snship Name' Township No. - Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> tt <br /> i�'�C:�t3{`; 1 1� d? �t' v. v. v. i 1 tv` -.t;;� <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> `�t, t C ❑ Cable Tool ❑ Driven ❑ Dug <br /> �r3Lt.` a�ixt��G117I� �:t]�.VL �t�3 ��i'1. ✓� �� ❑ Auger �Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. C <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> � � _i _i_ `�' �'C:.3"<1��„��.T.E'. <br /> --r--y- � � ..�.+..��` rt <br /> i � i �� ,USE ❑ Heating/Cooling <br /> p Domestic ❑ Monitoring <br /> yy � ; i � E �„}� '`�C] Irrigation ❑ Public ❑ Industry/Commercial <br /> � ❑ Remedial <br /> � �- ❑ TestWell ❑ Dewatering <br /> -;- -?- -; =- T ��� �, � <br /> , , � w <br /> � F'^"� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- �- ; —r- I '� � ❑ Steel ❑ Threaded ❑ Welded <br /> � 1 <br /> }� Plastic ❑ <br /> �I mile� <br /> "+' CASING DIAMETER WEIGHT / <br /> PROPERTY OWNER'S NAME `i in.to ��r� R. '�''����� Ibs./ft. t rjirt'to ��='ft. <br /> £ri_tu� h'�c�;�.l� Lc,rayti�ci.c;r� ,�.�o n. �b5.�n.6 ���,.,01 iC:n. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> ���� ,� i �y�� �il�,� SCREEN OPEN HOLE <br /> y . . <br /> Make � � � from ftto ft. <br /> �`s�'' .�c.t'i �.�� TYPe ` ' 't �.��z_Diam ,u <br /> ��a=ci¢r:�:� �c <br /> SIoUGauze Length � £�` <br /> Set between �" P�'�i;�, ft.and ��{'; ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR H MATERIAL�F FROM TO ,3�;° ft. ,�below ❑ above�and surtace Date measuredl�__�_,i.�;._Zg�;. <br /> PUMPING LEVEL(below land surface) <br /> �..�ct�+` bt >Je3.r`a11. „�'j ���� �{�,li,:'e ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION <br /> i��p. ��a ���tZ x '�'�(,!�Pitless adapter manufacturer �����:,1-� Model <br /> ❑ Casing Protection �12 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? �Yes O No <br /> Grout Material ❑ Neat cement �Bentonite <br /> from ��' b -�% ft. � ❑ yds!lO bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to fl. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ��,1.�� feet /�["�J6C t � direction ���type . <br /> Well disinfected upon completion? �7 Yes C No :�/�#►J�' <br /> PUMP <br /> ❑ Not installed Date in^�stalled �3����`�u�� r <br /> Manufacturer's name .��ly�i i?. bc �r.�3.tli�� 1 <br /> Model number Li,�'i�'�3(,+�'��j j HP ����a Volts ���� <br /> Length of drop pipe �� tt. Capacity g.p.m. <br /> Pressure Tank Capacity �L��.} �--'�.�i� ric <br /> �� Type:;1(7 Subme�sible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes � No <br /> WELL CONTRACTOR CEfiTIFICATION <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,ilneeded ��� U��-�� ���+ ��-1�� ���1 i�• i�� L <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. �icenseeeusinessName Lic.orReg.No. <br /> � <br /> _F,.. ��--�i�)--��i <br /> , Ati horized F�BpreS ntative Signature � Date <br /> �'.�'. �1:�hr<�3 i C`����--94 <br /> Name of Driller Date <br /> LOC;4L COF'Y ��6 ��$ HE-01205-04(Rev.5/92) <br />