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� � '� <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD � �$ 5 0 2 <br /> �p� Minnesota Statutes Chapter 1031 <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> Urc�o 118 ��.; 2� F�r=_-,(�t}t�;t: �. 14}' 9-9-�4 <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> 32£a5 Cou�tt Fi��ti 5 �n I�CE, Mt�. !�35(i ❑ Cable Tool O Driven ❑ 0�9 <br /> y g 3� ❑ Auger �Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> 3 Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> � � _i _i_ E`&�tE'_r' <br /> --r"-�- � � <br /> i � i � ,USE �Domestic ❑ Monitoring `� Heating/Cooling <br /> "-+" --- �- �- ❑ Industry/Commercial <br /> W � � � � E ❑ Irrigation ❑ Public <br /> ' T ❑ Test Well ❑ Dewatering � Remedial <br /> _1_ _1_ __ __ I ❑ <br /> _ � � � f-mi. � <br /> , CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- � � ' 1 <br /> � �- - -r- ❑ Steel ❑ Threaded ❑ Welded <br /> � LkPlastic ❑ - <br /> h �—l milv� � � <br /> � wt� 4 <br /> CASING DIAMETER WEIGHT <br /> � PROPERTY OWNER'S NAME � L f,� () Cs in.to j�.~i ft. SC�I". �i'� Ibs./ft. � ����0 3C' h. <br /> �.i I_.�� <br /> ��,t�a �' in.to ft. IbsJft. ��o t fl. <br /> , Mailing address if different than property address indicated above. in.to ft. Ibs./fl. in.to ft. <br /> SCREEN���,.���� OPEN HOLE <br /> Make a�u �u� from ft.to ft. <br /> Type �J � 1�$ � FA��{ Diam. <br /> SIoUGauze !` Length '�� <br /> Set between �,% ft.and � ft. FITTINGS:�• <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO J°f-�' <br /> MATERIAL ft. ¢�below ❑ above land surface Date measured �'g-�� <br /> PUMPING LEVEL(below land surface) - <br /> t'� �i "':t �-+ <br /> `'I�`� ��-�� •� {' � �t�j ft. after �-i hrs.pumping �� g.p.m. <br /> 77 WEIL HEAD COMPLETION <br /> Clay ��1it75tJ J L+ L�i r J}�Pitless ada ter manufacturer <br /> p �'�W[3'tE.'_"T� Model <br /> ❑ Casing Protection �12 in.above grade <br /> C�Y �"Z `� �•�}' �J� GROUTING INFORMATION <br /> Well grouted? �;Yes ❑ No <br /> �,�Y (�'�3��I '�(�1 � ��� '�lii�� Grout Material ❑ Neat cement �Bentonite <br /> from �' to .3�%ft. < ❑ yds. � bags <br /> �I from to ft. ❑ yds. ❑ bags <br /> 5�� �c� S ��t�� 1�3�� from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION.1 �p f/..L, <br /> �� feet ,� v'7;1 j T1 direction �_type <br /> Well disinfected upon completion? [�(Yes ❑ No <br /> PUMP (�_1 L.�r� <br /> � <br /> ❑ Not installed Date inst�JJe��„���,� <br /> Manufacturer's name <br /> SiE.. �w��: <br /> Model number �Volts �� <br /> '" Length of drop pipe �L�l tt. Capaciry �t g.p.m. <br /> Pressure Tank Capacity ��f��1C.�� ��LG <br /> Type:'�5 Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes O7$Jo <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 /> DC�V :,"I�C�DGi�, WEI,L tYtI.Lt,IIVG GU., �I�SC;. 27 7 74 <br /> Use a second sheet,il needed <br /> REMARKS,ELEVATION,SOURCE OF DAT t Licensee Business f�me -- (.ic.orR g.No. <br /> MAR 3 ��� , � �9-9� <br /> i�r �� � � . <br /> � /•� ✓ <br /> Authonzed RepresentaUve �gnature Date <br /> r•r�rz z�ei�y y-9-5�� <br /> i �� NameolDriller Date <br /> i <br /> ' LOCAL COPY 5 4 8 5 0 2 HE-01205-04(Rev.5/92) <br /> � <br />