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� <br /> �_ � _ <br /> WELL 1;OCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO. <br /> CountyName WELL RECORD �q,i n��� <br /> ♦ <br /> t:="�i?.<.i:�!:_�:: Minnesota Statutes Chapter 1031 ; f' � <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion <br /> n. <br /> '!i�°� � v. v. v. � � �� t�- <br /> Numerical Street Address or Fire Number and City of Well Location DRILLING METHOD <br /> � Cable Tool C] Driven ❑ Dug <br /> �'i,,t ;-� 3 ?�_'`�,�' ! C':.�� ' + t'`+?':, r Auger fJ Rotary C Jetted <br /> Show exact location of well in section grid with"X".y Sketch map of well location. C <br /> p. Showing property lines, <br /> N `� roads and buildings. DRILLING FLUID <br /> I i � i , � <br /> _r•' 1_ _1 —1_ . �-: -.�:`} t . . <br /> � <br /> i � i i USE <br /> --+- --- �- �- �� - !7y Domestic C Monitoring ❑ Heating/Cooling <br /> W � ' � ' E � _' Irrigation C i Public ❑ Industry/Commercial <br /> � : .i <br /> _1_ _1_ __ __ T � �: Test Well ❑ Dewatering . . <br /> � � i <br /> f-mi. . ._.-_- CASING Drive Shoe? Yes No HOLE DIAM. <br /> , , I _.._ •--- <br /> '-;- �- - —�' 1 �, , . . G Steel 7hreaded I] Welded <br /> h---�,„Jle'� �s � Plastic 7 <br /> CASING DIAMETER WEIGHT <br /> �':<: �6f to,(��'n. <br /> PROPERTY OWNER'S NAME in.to ft. ` '�'� Ibs./tt. � / <br /> '�i' � `-�_ � �=�`-" in.to ft. Ibs./ft. in.to ft. <br /> Mailing address if ditterent than property address indicated above. in.to ft. Ibs./ft. in.[o ft. <br /> SCREEN OPEN HOLE <br /> �. 4�l }^,:-' 15 . ,-.�.: � v S <br /> . . �f,, Make 1C����„ from ft.to ft. <br /> i � � . - ;'3 Type t_ ct �,..a�.. '.E-;°;_i. Diam. •.re _ <br /> _r�'�`_ . .� . - - t <br /> SIoVGauze 7�' Length <br /> Set between ��''''_;ft.and i;- ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> FORMATION LOG COLOR HARDNESS OF FROM TO E �:i ' tt. �; below � above land surface Date measured —1`---:-1`�_ <br /> FORMATION <br /> .- ti PUMPING LEVEL(below land surface) <br /> � <br /> ` � �E .: � ft. after hrs.pumping a.p.m. <br /> /.� ,- Tr <br /> WELL HEAD COMPLETION <br /> � �. Pitless adapter manufacturer i r��.��."+1 �'� '��. �%�_�" Model <br /> i ` i �f F' `C] Casing Protedion <br /> -� <br /> e <br /> :..Lc:1` Fc �, t`K' - � i�.`i �"; � GROUTING INFORMATION <br /> Well grouted? G1-Yes C No <br /> - � �� ;� S � Grout Material f�, Neat cement ❑ Bentonite <br /> ,'.i. _,. . _ . <br /> from to t:ft. I; yda E; bags <br /> from to ft. I] yds. C bags <br /> from to ft. � yds. ❑ bags <br /> NEAREST SOURCE OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon compietion? Cd,�Yes ❑ No <br /> �r� PUMP <br /> ❑ Not installed Date installed `y j' r j`�d�;��. <br /> ' Manufacturer's name ���� <br /> �� � Model number HP •1.�.f. Volts�� <br /> Length of drop pipe j i,"l i ft. Capacity ,,_ a.p.m. <br /> " � Pressure Tank Capacity -�:Tz'�j�-.,�•_� -. <br /> Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating O Jet J <br /> ABANDONED WELLS <br /> � � t�� Not in use and not sealed well on property? ❑ Yes L7.�lo <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdiration and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> �... -. _ _ , <br /> (; .�i.4 r _ 'e�.�__ ^ � . . . . ..,.. � i <br /> . ..,. . ��ri_: . ...._ .�...i.+�. . - n . .._.. f i . . <br /> Use a second sheet il needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Liaensee Business Name lic.or Reg.No. <br /> _ .;/'`��.�' � ' i: - <br /> ,�;--./� �-r' `�- ���^�� _ <br /> Authonzed Represenfahve Skyanture Date <br /> _.,.7_� <:� - 1''-. <br /> Name ol Driller Date <br /> LOCAL COPY � � �J �� � HE-01205-03(Rev.9/91) <br /> �', <br />