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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELLRECORD 3 5 6 2 2 <br /> tI F�V U,, Minnesota Statutes Chapter 1031 <br /> Township Name Township No. - Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> 1 yi ! S V <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> C v.i.-pry C 1Vr S ❑ Auger Rotary ❑ 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 buildings. DRILLING FLUID <br /> . <br /> i 1 rk USE ❑ Heating/Cooling <br /> PQ Domestic ❑ Monitoring <br /> W i I E / ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> �� ElTest Well E-) Dewatering O Remedial <br /> -1- -1- T <br /> F' "' d CASING Drive Shoe? ❑ Yes 151 No HOLE DAM. <br /> --r- <br /> El Steel [I Threaded El Welded <br /> 1 �+v Plastic ❑ <br /> Vj`�` <br /> 1 milr r <br /> CASING DIAMETER WEIGHT ! <br /> PROPERTY OWNER'S NAME t in.to J —ft. lbs./ft. !? in.tX ft. <br /> n.to ft. lbs./ft. -7 in.tot 44 ft. <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make �c�^' .•"' from ft.to ft. <br /> jType 'r+, Diam. <br /> 1 r r 0 Slot/Gauze Length 'l1 r <br /> Set between ft.and_. H 4-- _ft. FITTINGS: � <br /> 6 <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TOi_ c!3 <br /> MATERIAL ! ft. (below ❑ above land surface Date measured r <br /> ` \ PUMPING LEVEL(below land surface) <br /> ft. after <br /> hrs.pumping �� ) g.p.m. <br /> tt WELL HEAD COMPLETION t{ SS / <br /> 1 `� c, .! �J�'• M X Pitless adapter manufacturer W�^ k. Q1Z f e— Model <br /> 1 ❑ Casing Protection RSL 12 in.above grade <br /> r <br /> GROUTING INFORMATION <br /> Well grouted? Yes ❑ No <br /> Grout Material ? Neat cement 04 Bentonite <br /> from to Zil- ft. 'K yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMIN{ATION <br /> t-� feet Nri direction •� `}� type <br /> Well disinfected upon completion? r,Yes ❑ No ( . <br /> PUMP <br /> ❑ Not installed Date installed e 1 <br /> RECEIVERECEIVEP Manufacturer's name <br /> Model number HP 14y- Volts c 31 <br /> APR 2 2 1994 Length of drop pipe ft. Capacity t J g.p.m. <br /> Pressure Tank Capacity U a 1r°?11 X <br /> Cffy OF ORON0 Type: 0 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes A<No <br /> WELL CONTRACTOR CERTIFICATION <br /> r,a+ <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,if needed a.1 .k(CC- �7 a./14 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. 4 <br /> A orized Representative Signature Date <br /> 07-In <br /> Name of Driller Date <br /> LOCAL COPi 15356221 HE-01205-04(Rev.5f92) <br />