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� <br /> s <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL RECORD � � � ��� � <br /> � Minnesota Statutes Chapter f031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion <br /> n. <br /> Oma�o 118N 23W 29 �,.I��. ��. <br /> Numerical Street Address or Fire Number and City ot Well Location DRILLING METHOD <br /> 34fl5 Coun R�oac� 6 r��3�� C Cable Tool Driven �� Dug <br /> ❑ Auger � Rotary _ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ ' <br /> Showing property Nnes, <br /> N roads and buildings. DRILLING FLUID <br /> I � ' <br /> --r-�- -j -1- <br /> i � <br /> i � � � USE � <br /> --�- -',- �- �- � Domestic 7 Moniroring C Heating/Cooling <br /> W � ' � ' E Irrigation � Public G Industry/Commercial <br /> i <br /> _1_ _1_ __ __ ���._I Test Well = Dewatering '.7 <br /> 1 � ' <br /> ' f�mi. CASING Drive$hoe? C Yes � No HOLE DIAM. <br /> --�- �- ; -r- I � C Threaded L 1 Welded <br /> � ' 1 <br /> �—I+nile'� F��� � S •"r tt��... � � Plastic �' glitP <br /> ' CASING4DIAMETEF ��� ' WEIGHT $ 170 � <br /> PROPERTY OWNER'S NAME in.to ft. Ibs./ft. in.to ft. <br /> � in.to ft. Ibs./ft. _in.to fl. <br /> Mailing address if ditterent than property address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make Tr3VYY'1 from ft.to ft. <br /> T <br /> 7ype k1�"•�� Diam. n <br /> SIOUGauze �5 Lengthl���� <br /> Set between ��i tt.and 17n ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> FORMATION LOG COLOR HARDNESS OF FROM TO '� ft.j}� below ❑ above land surface Date measured <br /> FORMATION � � <br /> PUMPING LEVEL(below land surface) <br /> �1 b�+ Q � ft. after hrs.pumping z�g.p.m. <br /> WELL HEAD COMPLETION <br /> `'�� �m1 i� 2 '� �Pitless adapter manufadurer ttu..,.A.. Model -r <br /> �cs <br /> i7'Casing Protection <br /> 4t4y b�.te gray 25 $Q GROUTING INFORMATION <br /> � Well grouted? � Yes � No <br /> 1 �t $�1� ��, $O �5 Grout Material � Neat cement ❑ Benronite <br /> trom_�to�Q_ri. J yds. L bags <br /> from to ft. ❑ yda ❑ bags <br /> Sh31e & gravel red brvwn 135 157 from to n. o ya5. ❑ bags <br /> NEAREST SOURCE OF POSS�BLE CONTAMINATION <br /> � � (�g�l �(� �7 1,7� feet direction type <br /> N[ell disinfeded upon completion? �Yes ❑ No <br /> PUMP <br /> Not installed Date installed <br /> Manufacturer's name RIZ t'�C <br /> Model number HP 3�4 Volts 23t1 <br /> Length of drop pipe �� ft. Capacity �� a.p.m. <br /> Pressure Tank Capacity <br /> Type: �I Submersible ❑ L.S. urbine� ❑ Reciprocating f J Jet ❑ <br /> ABANDONED WELLS <br /> Not in use and not sealed well on property? � Yes �No <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdication 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 sneet,il needed fi}�sprtte Ts7ts11 T}ri 11 i nrr i�_ _ T�_ 2'Z,2 94 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name --, �'T Lic.or Reg.No. <br /> �e <br /> �'Y.. � ..._� �a���iT�� <br /> .+futhonzed Represen a ve S�ganture �te <br /> m o a <br /> LOCAL COPY � � � � � � HE-01205-03(Rev.9/91) <br />