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N'�LL LOCPTION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> Countv Nas,�` WELL RECORD 5 4 8 5 5 6 <br /> f�"����'n Minnesota Statutes Chapter 1031 <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> �-f��� �1� �:� cs� ��s� �—��}—y�a <br /> �,. ,. ,. <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> L Su��� �,�� ��,����i ��• i_�Jg.� ❑ CableTool ❑ Driven ❑ Dug <br /> �Vt' � ❑ 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 /> ry roads and buildings. DRILLING FLUID <br /> I i ' � <br /> --r--7- -1 -1- ff��,f <br /> � � "� <br /> i � i i �y�"' .USE ❑ Heating/Cooling <br /> ._+_ ___ _ �_ � 4�1 Domestic ❑ Monitoring ❑ Industry/Commercial <br /> W � i � � E ❑ Irrigation ❑ Public <br /> ' j ❑ Test Well ❑ Dewatering ❑ Remedial <br /> _1_ _1_ __ 1_ � <br /> I j � <br /> f-mi. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> '-i- �- � -�' j ❑ Steel ❑ Threaded ❑ Welded <br /> �-1 milr'—� x�LK�� LI,�Plastic ❑ <br /> CASING DIAMETER WEIGHT <br /> PROPERTYOWNER'SNAME E� in.to_��ft. 4T'u?r.�i Ibs./ft. _���(�t f�;; <br /> Jl.t:i ►7E?I1ziC:ll �fC.�1G.".;' in.to ft Ibs./ft. <br /> �r Tj`�—�-�:� <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> L�,�,,.,i. SCREEN 4,..,,., OPEN HOLE <br /> �L�� '�f+:�y1�3r� �j4"�5i�cly Make �C�iut:a�Il from ft.to ft. <br /> �i17"lI1E.'�C)f�Ct3� MCI. rJr3.3�iJ TYPe ����I3�'���,--��� Diam. �p <br /> SIoVGauze Lenqth �i <br /> —�" <br /> Set between �_�,F.�^ft.and �L�ifl. FITTINGS: <br /> STATIC WATERLEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO �t�i `�L�`��Y <br /> MATERIAL ft. f�Cbelow ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> L-ld� �SC `��'TKj. .�'�' �� ��.l � ft. after hrs.pumping g.p.m. <br /> c��,.,,..Y WELL HEAD COMPLETION r�..�,���,��, <br /> .�catat � ��;;�`:� �G y��itless adapter manufacturer �vl Model <br /> ❑ Casing Protection ;�12 in.above grade <br /> GROUTING INFORMATION <br /> Wellgrouted? QYes ❑ No <br /> Grout Material ❑ Neat cemeW �Bentor»►�: � <br /> from �� ro 3 ft. O yds. I$.bags <br /> from to ft. <br /> from to fl. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION ,�,,, <br /> �l f)' feet 1����" direction `^�'��+� rype <br /> Well disinfected upon completion? C�Yes ❑ No `� <br /> PUMP <br /> ❑ Not installed Date installed � <br /> - Manufacturer'sname ����-���,� <br /> Model number HP _�_ Volts <br /> _ Length of drop pipe ft. Capacity � g.p.m. <br /> � Pressure Tank Capacity ��� � �:��,- �' <br /> Type:.❑ Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)7 ❑ Yes LTNo <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 /> D()Pd S��Lt=3 WE:I.I, I�,L.TNG C:U. 271 1�r. � <br /> Use a second sheef,if needed I <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licens e eusiness Name Lic.or Reg.No. <br /> ---_..---- .. <br /> > �. , ,-, .. <br /> ./ .�"7`~— r �—L�x—g.`� <br /> ;./�- `�-"� _ <br /> � Authorized Representative Signature Date <br /> �''.P. Nic�ia.lxxl 2-2�—�`_� <br /> � Name ol Driller Date <br /> x LOCAL COPY � q,�� �6 HE-01205-04(qev.5/92) <br />