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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD 5 613 4 2 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> � 23 29 44T0002 �. 216 ;_�'_�S <br /> Numerical Street Address and Ciry of Well Location or Fire Number DRILLING METHOD <br /> c ❑ Cable Tool ❑ Driven ❑ Dug <br /> � 3J� ❑ 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 /> ii {..._._.__...,_._..; . :�_ ' <br /> I i _y -L- ___F .. . <br /> _'r' ti- � <br /> � � � ❑ Heating/Cooling <br /> _a- _-- i- ,_ � ,USE Domestic ❑ Monitoring ❑ Industry/Commercial <br /> W i � � E � �Irrigation ❑ Public <br /> _1_ _s_ __ __ T ❑ Test Well ❑ Dewatering O Remedial <br /> I � ' <br /> ' '/_-mi. f 1 CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- �- ; -r- � o`-y'r�L ❑ Steel ❑ Threaded ❑ Welded <br /> � �Plastic ❑ <br /> �I milr� .__ <br /> ` ,� � CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �I___in.ro�Q�ft. �JDR Z1. Ibs./ft. I 7�� � <br /> - in.to_ _ft. Ibs./ft. �in.to�� <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./fl. in.to ft. <br /> SCREEN_��_ OPEN HOLE <br /> Make ��1 from ft.to ft. <br /> 1 <br /> Type Diam. <br /> SIoUGauze 1(1 Length �� <br /> Set between �ft.and�i_i-tt. FITTINGS: O� <br /> G11 <br /> STATIC WATER LEVEL S <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO tt.Ll below ❑ above land surface Date measured <br /> MATERIAL X <br />� PUMPING LEVEL(below land surface) <br /> ft. after hrs.pumping_ n�g.p.m. <br /> WELL HEAD COMPLETION <br /> L'lc.�v 1.e1,2� $ 2 Z ]'Q Pitless adapter manufacturer �"�1��£�3t�r Model <br /> J <br /> ❑ Casing Protection �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 /> � T�$1� S t�n �5 from to ft. ❑ yds. ❑ bags <br /> �Ju from to 8. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Sl�t �Y.'Q�112 S 1S5 l7 �S� feet � direction G�ty �ype <br /> Well disinfected upon completion? �] Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed 6-IU--95 <br /> /$� G'rs� S � �1 anufacturer's name ���+��,it <br /> us <br /> Model number �Gc++ 1 ets�f'� HP 7//. Volts 7� <br /> —�re� <br /> 1 1 Length of drop pipe ft. Capaciry g.p.m. <br /> '� Y�1�Q�7 � 21 2i pressure Tank Capacity <br /> Type: {:l Submersible ❑ L. . ��r Jet ❑ <br /> A <br /> s <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes No <br /> WELL CONTRACTOR CERTIFICATION - <br /> t <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,i/needed �OTl st(�,Q�,$ �'IQ1,1 ���,Z�11� CQ�� yjjC• G71/2 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. �icensee Business Name Lic.orReg.No. <br /> � : 6-9-95 <br /> 'v���� -Au ho z Representative Sig��� Date <br /> N i 2 1��Ju Ered Leitrv 6-�3-95 <br /> JP. Name o Driller Date <br /> LOCAL COPY 5 613 4 2 HE-01205-04(Rev.5/92) <br />