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� ._., <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> CountyName , . WELL RECORD - �} <br /> 1:':'�lftG%i3i1 �� `'° �' �] /� <br /> Minnesota Statutes Chapter 1031 '/ �— s�J"Y �i � <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> fl. <br /> :..;zf.;�r, � ��: µ :.. <br /> . �. �. ��, <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> �`��;{� (,-Cil,;yj�.1 li(��ii.. �', i.,l�ii'.-i Lc?,�S`�� �°1. ❑ Auger ❑ Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". ~ Sketch map of well location. ❑ <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> I i _1 _1_ y�:n�it,�;;i.i.��._. <br /> --r--ti- � i <br /> � � � � .USE ❑ Heating/Cooling <br /> _a_ ___ �_ �_ q Domestic ❑ Monitoring _; Indust /Commercial <br /> W � � E ❑ Irrigation ❑ Public � ry <br /> ' T ❑ Test Well ❑ Dewatering O Remedial <br /> _1_ _1_ __ _' I <br /> I ; ' <br /> 2-mi. CASING Drive Shoe? <br /> � , .. q•Yes ❑ No HOLE DIAM. <br /> --;' �' - —�' j �f L n�j�.� ❑'$teel C Threaded � ❑ Welded <br /> � �' �d ❑ Plastic ❑ <br /> � 1 mili� � <br /> C� <br /> CASING DIAMETER WEIGHT <br /> �.:.�; 1i, , ' i:� <br /> PROPERTY OWNER'S NAME in.to ft. ��" Ibs./ft. � "/��in.to ��� ft. <br /> �_�)`t .�x?4:.:". <br /> in.to ft. Ibs./ft. � in,to'�-�- ft. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./fl. in.to ft. <br /> SCREEN _7��__T_ OPEN HOLE <br /> . E> i c . .'} r L�<t,. k• _ <br /> ,. <br /> `. ' Make �.• � ... ....� from , ft.to ft. <br /> �4.i:(; _: :�, t .,. ' :i.:i: TYPe .`� -�. ..+7,.a ,... .,a —�-=--- <br /> I �•• � �� Diam. <br /> SIoUGauze � Length <br /> � Setbetween ��.��- ft.and �,"f.i�, ft. FITTINGS: <br /> HARDNESS OF STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR FROM TO ��+_` ft.�1 below ❑ above land surface Date measured � - —�'�': <br /> MATERIAL <br /> PUMPING LEVEL(below land surface) <br /> f l�'���r� ��y �-��`� ft. atter hrs.pumping g.p.m. <br /> i�.....:. . . <br /> WELL HEAD COMPLETION <br /> �i'��' �='�.�i �:.�;�; CN;Pitless adapter manufacturer ;;,���,•1������>,� Model <br /> ❑ Casing Protection C�12 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? ❑ Yes []+,"No <br /> Grout Material ❑ Neat cement ❑ Bentonite <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> trom to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? �`Yes ❑ No <br /> PUMP !"!.,i"`_<.,` <br /> ❑ Not installed Date installed r <br /> � —�.���iC�!.+�. <br /> Manufacturer's name <br /> Model number ��� HP -- Volts `'"" - <br /> i Length of drop pipe � c� 1t.;., apaei m. <br /> -`�7`s�`3.'.f.�_1� ,..� ., 9'P' <br /> Pressure Tank Capacity <br /> Type: Cf�Submersible ❑ L.S.Turbine ❑ Reciprocating L-1 Jet ❑ <br /> ABANDONED WELLS <br /> ; Does property have any not in use and not sealed well(s)? ❑ Yes �No <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 /> L�.ia >�.t..�i.Y .1.�. �4'tI:��1� i.t1,.��,,#�.;.:,1_ �4. r i,� �'�: <br /> Use a second sheet,if needed "' '"' ' ' <br /> REMARKS,ELEVATION,SOURCE OF DATA,eta Licensee Business Name Lic.or Reg.No. <br /> r �r-"�� .�..�;x•�= ;' �—t�--_ti <br /> ' � Authorized Representative Signature � ' Date <br /> .v .. . i;C..`�r'.�:.;Z�C:i; V—�'�--�t�, <br /> t <br /> Name ol Driller Date <br /> LOCAL �OPY � � � 4 4 � HE-01205-04(Rev.5/92) <br /> � <br />