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WELL L�'CP,T!ON+r MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD 5 4 8 5 3 2 <br /> �tIY��J3.n Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> 11 , �� I,c�t� 7 ulc3 C:ry�t.=�. " <br /> t�rc�r�, �' ?3�` <br /> 11—�— <br /> Numerical Street Address and City of Well Location � DRILLING METHOD <br /> M. G Cable Tool ❑ Driven ❑ Dug <br /> .����.1: :�C7Fi1Q1'SEt ��.`I�i1� �. vL�Gl'�CJ �1. �?�?� ❑ Auger O Rotary ❑ Jetled <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ r• <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> I � _i _i_ ` F3E'Y�`: <br /> -r--7- � i <br /> � � i i .USE ❑ Heating/Cooling <br /> ._+_ ___ �_ �_ �Domestic ❑ Monitoring <br /> yy i i E ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> ' T . ./1 ❑ Test Well ❑ Dewatering O Remedial <br /> _1_ _1_ _'_ _' I . t� <br /> i <br /> I � �""° *�r�� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- � -� � 1 ; <br /> - � �- —�' � ❑ Steel ❑ Threaded ❑ Welded <br /> � I milr'—� �j;(�,�' [3�Plastic ❑ <br /> , [i <br /> U� CASINC�,DIAMETER WEIGHT <br /> != 1�y i (�(� i(, <br /> PROPERTY OWNER'S NAME in.to ft. Ibs./h. i to R. - <br /> �tVc.�te�w; & A.��aC3.c"ite5� .LI1C. in.ro tt. ibs./ft. ��.to�. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> ��.!{�C� V3.Jt1.I� I���I,V�' S�.� 1{� SCFEEN OPEN HOLE <br /> ��1 Prs�irie, �. 5�:i�� Make �r'3Y'Cj .�ix1]_f;.� from ft.to tt. <br /> TYPe �a'�����yo-�t-c.cae..�,a„�Diam. �R <br /> � � Slot/Gauze Length �' <br /> Set between �z(2�tt.and_}_�'�__ft. FITTINGS: <br /> HARDNESS OF STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO yf�F ft. �be�ow ❑ above land surface Date measured $1—:'—gt� <br /> PUMPING LEVEL(below land surface) - <br /> �.�.,rZV .�5 (i� �('� ft. after_ hrs.pumping g.p.m. <br /> � WELL HEAD COMPLETION <br /> �a'1'1Cy �. �(,.'� ��,�� ��itless adapter manufacturer ���+��� Model <br /> O Casing Protection (�72 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> Grout Material ❑ Neat ceme i ❑�entonite� ., r <br /> �rom �'� to ''{� ft. �", ❑ yds.t�? bags <br /> from to R. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION x <br /> �,, feet �•L/���r direction .�c.�/�'/� type <br /> Well disinfected upon completion? C�Yes ❑ No <br /> PUMP <br /> O Notinstalled t r�sta�lp(�� . 11—i��—��G <br /> Manufacturer's name ��'t"������� <br /> Model number J HP V L$-�= <br /> Length of drop pipe y ft. Capaci� � g.p.m. <br /> Pressure Tank Capacitv _ UL e.��.'L'!]"�"�' 1'c3 C <br /> Type:�] Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �QVo <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 /> Use a second sheet,i/needed �� �'������ ��� �I�1� �"1 x�• l�t r L <br /> ' <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.orReg.No. <br /> _____ <br /> APR 4 1995 ��``"`� .. 11—�—y4 <br /> ..--. �,�`=--. <br /> _ Authorized Representative Signature Date <br /> I�.F. I'�"�iC?1'1 3�—L'—�� <br /> Name ol Driller Date <br /> 0 <br /> M1 <br /> LOCAL CO�Y 5 4 8 5 3 2 HE-01205-04(Rev.5/92) <br />