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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1.LOCATION OF WEM WATER WELL RECORD MINNESOTA UNIQUE WELL NO. -15 )i,.. <br /> County Name for Water Sample 1 . �,_ 7 <br /> ( Minnesola Statutes 156A.01..08 <br /> Township Name I Township Number I Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> / (t. <br /> or or <br /> S W1 <br /> Distance and Direction from Road Intersection or Street Address and City of Well Location 5, DRILLING METHOD <br /> 10 Cable tool 40 Reverse 70 Driven 100 Dug <br /> Show exact location of well in section grid with-X." S¢elch map of well location. 20 Hollow rod 50 Air 80 Bored 110 <br /> N <br /> Addition Name ^� 31!�Rotary 60jetted 90 Power gauger <br /> 6.DRILLING FLUID <br /> _.. <br /> Block Number 7. USE <br /> W E <br /> ODomestcc 40 Monitoring 80 Heat Pump <br /> I i <br /> f-miLot Number 20 Irrigation 50 Public 90 Industry <br /> . IN <br /> 30 Test Well fi❑Municipal 100 Commercial <br /> 70 Air Conditioning 110 <br /> 1 mile 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME HEIGHT:Above/Below <br /> 1[I Black 40 Threaded <br /> Surface 7 ft. <br /> 20 Galy. 50 Welded <br /> � Drive Shoe' Yes— No- <br /> Address 1/79� /v 30 Plastic 60 <br /> in.to - ft. Weight lbs./ft. in. to t. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO <br /> FORMATION in.to ft. Weight lbs./ft. in. to_�t. <br /> - <br /> in.to ft. Weight lbs./ft. in. tort. <br /> 9.SCREEN Or open hole <br /> from ft.to. ft. <br /> Make <br /> Type Dis. <br /> Slot/Gauze Length FITTINGS: <br /> Set between i - ft.and - ft. <br /> 10.STATIC WATER LEVEL <br /> f , <br /> ft.O below ❑above Date Measured I <br /> land surface <br /> 11. PUMPING LEVEL(below land surface) <br /> _ ft.after hrs.pumping 9-P in. <br /> ft.after hrs.pumping- 9-P in <br /> 12.HEAD WELL COMPLETION <br /> 10 Pitless adapter,manufacturer 'c � _model <br /> 20 Basement offset 30 At least 12"above ground <br /> 40 Plastic casing protection <br /> 13.WELL GROUTED? <br /> 0Y es ❑No <br /> 113Neat Cement 20 Bentonite 30 <br /> Grout material from to ft.cu.yds. <br /> J <br /> J14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? EINes ❑No <br /> 15, PUMP <br /> Date installed _ ❑Not installed <br /> Manufacturer's name <br /> Model number HP Volts <br /> Length of drop pipe ft. capacity 9-P in <br /> Material of drop pipe <br /> _ Type:1&Submersible 30 L.S.Turbine 50 Reciprocating <br /> 20 Yet 411 Centrifugal 60 <br /> 16. EXISTING WELLS <br /> Unused well on property? ❑Yes H'Sl. <br /> Use a second sheet,if needed <br /> z Abandoned ❑ Permanent❑ Temporary❑ Not sealed <br />+•`>-'"��' 17. REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> 18.WATER WELL CONTRACTORS CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. <br /> Licensee Business Name License No. <br /> Address <br /> Signed Date <br />- Authorized Representative <br /> Date <br /> Name of Driller <br /> <-, 5/74 30M <br /> LOCAL COPY 1-45 - <br /> iiia 3aM <br /> HE-01205-02(Rev.10/85) 2/82 IOM <br />