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�' � MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> WELL LOCATION <br /> CountyName WELL RECORD 4 7 g� �� � <br /> i�F:�ll�rE:�.,:1.�i Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion <br /> n <br /> � y. " _ . " . 3 � "�„{.. . _. <br /> 1.:�(al�.t i . � �. � v�..�.j7ry �-.Y' y. _. <br /> Numerical Street Address or Fire Number and City of Well Location DRILLING METHOD <br /> �� Cable Tool �� Driven _ Dug <br /> '.'� .-�.i...`:i.��E�_:�. iiC. � i�.i.� .t(;r "'ty-;. i:: Auger �ri� Rotary Ci Jetted <br /> Show exact location of well in section grid with"X'. Sketch map of well location. <br /> Showing property lines, � <br /> N roads and bwldings. DRILLING FLUID <br /> I � _i _i_ >'' :'" _,_..._ <br /> .'r- y- i � ... . . <br /> i � i i � USE � <br /> --+- -;- �- �- � s Domestic Monitoring ❑ Heating/Cooling <br /> W � ' � ' E - Irrigation i 7 Public 1 Industry/Commercial <br /> � <br /> _1_ _1_ _'_ __ T y ❑ Test Well � Dewatering _ <br /> � ' L <br /> I � f"^Q , CASING Drive Shoe? �'.Yes � No HOLE DIAM. <br /> --�- �- � —�� I �`� G Steel � Threaded ❑ Welded <br /> , 1 `- <br /> a�f � Plastic f l <br /> 1----1 mile—� �" <br /> " ����"� CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME in.to ��- �ft. f''• ' Ibs./ft. �in.to�ft. <br /> v j tJl':;:� :��f�_!�l f;s : _.: in.to ft. Ibs./ft. in.to ft. <br /> Mailing address if ditterent than property address indicated above. in.to ft. Ibs./ft. in.to_ft. <br /> SCREEN OPEN HOLE <br /> .. t n>:.. •K?}'�F= .�'.:.G: Make Cy�'u`i`>C'i:x from fl.ro ft. <br /> � _..i� .._.:i . .._ � �,. ., _ �_ _, Type `.'i'Cu�ii � :.f:<�_ Diam�ss — <br /> SIoVGauze � r,_Length � <br /> Set between ��'�� ft.and `` ft. FITTINGS: � <br /> s <br /> STATIC WATER LEVEL <br /> " FORMATION LOG COLOR HARDNESS OF FROM TO �`"� ft. ❑.;below ❑ above land surface Date measured "'� �`,"" <br /> FORMATION ., <br />' PUMPING LEVEL(below land surtace) <br /> r�. , -� F �� , <br /> :J j.:{Y; � c ?�;:( Y t - �,'' ft. after hrs.pumping a.p.m. <br /> i ; , { WELL HEAD COMPLETION }.;`._-�,�� `-{.,,..�. <br /> �:;��1;r- �:.. t '�_ q Pitless adapter manufacturer - Model <br /> i 1 Casing Protection <br /> GROUTING INFORMATION <br /> Well grouted? �;Yes ❑ No <br /> Grout Material .L] Neat cement ❑ Bentonite <br /> ^ from to ft. ❑ yds. p bags <br /> from ro ft. ❑ yds. ❑ bags <br /> irom to tt. ❑ yds. ❑ bags <br /> NEAREST SOURCE OF POSSIBLE CONTAMINATION <br /> feet direction rype <br /> Wel�disinfected upon completion? .,p Yes [=i No <br /> PUMP <br /> C Not installed Date installed �`�`' ' ' <br /> Manufacturer's name �'Y-5-�'`''�Y <br /> „ <br /> Model number HP 1.='� Volts . <br /> Length of drop pipe ft. Capacity �'` a.p.m. <br /> � ; �. <br /> Pressure Tank Capacity �«='. l�:=''-. <-,`'� <br /> � Type: C'y._Submersible ❑ L.S.Turbine � Reciprocating � Jet ❑ <br /> ABANDONED WELLS <br /> � Not in use and not sealed well on property? I 7 Yes �"No <br /> + � C_ - <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 seaond eet'nee� � ._ ;L� _ `' r e.%3 � _ `;�(,, `i;; 7',i., .i ', i: <br /> REMARKS,ELEVATIO RC OF A , c. Licensee Business Name � *L�c.or Reg.No. <br /> -::.� ��= �.�; �. ,. �: _ . <br /> � A�'uthorized Represenfative Siganture � Date <br /> � . . '�`�i.: . �x . - ��a-�'G, <br /> Nameo�Oriller Date ' � <br /> LOCAL COPY '-} i � J � � HE-01205-03(Rev.9/91) <br />