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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> �;,��.. WELL RECORD 5 3 6 2 5 0 <br /> �-���-Y� Minnesota Statutes Chapter 1031 <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> tt. <br /> t°�t4-�nc: 11"/ :��? i:'�; 3��,.{qt��,�, �. t�:% �:_•�C � <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> �'F11i .ci11S�'�X RC3�?L� l�lrnli+fi �• ❑ Auger `�C] Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". �� Sketch map of well location. ❑ <br /> Showing property lines, <br /> s roads and buildin s. DRILLING FLUID B. �l <br /> I i N i i J�+�-y�X 9 <br /> --r---r -1 -1- 5r ,r <br /> i � � i ,.l��� ,USE �Domestic ❑ Monitoring � Heating/Cooling <br /> yy � ; I � E �Ni ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> � T ❑ Test Well ❑ Dewatering �� Remedial <br /> _1_ ___ __ 1_ I ❑ <br /> I ; ' <br /> �''"'� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- � � ' 1 <br /> , �' - -�' ❑ Steel ❑ Threaded ❑ Welded <br /> � � Plastic ❑ <br /> �—I mile—� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � f� ", <br /> in.to_�.�yt. Ibs./ft � ,?� in.to�� � ft. <br /> ���� �� ��r��� in.to ft. Ibs./fl. : �r�� in.to.�[�.ft. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> '���,� '���� ���� SCREEN OPEN HOLE <br /> ���,�„�X' �. �r.��;- Make a�C��1�1SC�J1�1•^� from ft.to ft. <br /> '-.i TYPe r�?'�#i��`cs r�i-m� Diam. �M <br /> Slot/Gauze Length <br /> Set between ft.and �4� ft. FITTINGS:�{Z���� <br /> . STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOF HARDNESS OF FROM TO t^; ft.� below ❑ above land surface Date measured 1���~ � <br /> MATERIAL - <br /> PUMPIN��EVEL(below land surface) 1 <br /> '�C <br /> LZ���' Y��.C7�r� S �" y;i;' i'��• ft. after hrs.pumping E•Yj g.p.m. <br /> , WELL HEAD COMPLETION �.��,�x, <br /> �,x� (�jr��s� �L�t �i(y� �7 Pitless adapter manufacturer Model <br /> ❑ Casing Protection �] 12 in.above grade <br /> .+ �t <br /> �I�K.� �I'ari �{�� i e.�i°� GROUTING INFORMATION <br /> Well grouted? �I Yes ❑ No <br /> � t` x �-�C� t Grout Material ❑ Neat cement � Benronif,e <br /> Cl�.y G7C� i._;(; 1.�.> from �' to ��` a. � ❑ yds.� bags <br /> „ 1 from to ft. ❑ yds. ❑ bags <br /> `�"�� Tc�l� � t 4j� �t:e; from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ��feet '���v_�� direction��,. a� type <br /> Well disinfected upon completion? �Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed ��� �'�'�"f� <br /> Manufacturer's name ���� <br /> Model number - HP_��__ Volis L]�e <br /> Length of drop pipe °"t R. Capacity �l. g.p.m. <br /> Pressure Tank Capacity �.� h"�Y�%�- <br /> Type: � Submersible f7 LS.Turbine ❑ Reciprocating ❑ 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 /> Use a second sheet,il need�V � � �y ����� �� I�� �•� �'��` �/j� � <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name Lic.or Reg.No. <br /> .+'� . j �'','�� � <br /> �,�'` � � ;c—�`�--�� <br /> - Authorized Repres2ntative Signature Date <br /> �� I�'l�'Jy �—�`;���'e <br /> Name of Driller Date <br /> LOCAL C�PY "1 �h / 'A O HE-01205-04(Rev.5/92) <br /> �J V L�d <br />