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STATF'.OF MINNESOTA DUPARTMENTOI HEALTH <br /> KATION Of wF.LL MINNESOTA UNIQUE <br /> ampl WELL NO. 0 0 <br /> y Namr _ WATER WELL RECORD /n,ware.Sample <br /> fi. Minntrora St.—,/51A.III 08 <br /> ship Name Town,hlp Number Rang.Numher Sec Ron Nn. Frac oon 3. PROPERTY OWNER'S NAME <br /> ,,,and Direction from Road Intersections or Street Addres.and City of Well Lucaliun Address <br /> coact location of ywell in-.u.grid with"X." Sketch map of well location. 4. WELL DEPTH(completed) Dale of Completion <br /> ' N AJJiDon Name ✓,f'� <br /> 5 1❑Cahleln,it 4❑Re—w 70Drieen o❑Deg <br /> Block Number 20Hollnw rod 5❑AIr 808ored 110 <br /> - <br /> if Jc Rotary 6❑jetted 9❑Power Auger <br /> Lot Number 6. USE <br /> f❑Domeslic 4❑Puhlic Supply 70 Industry <br /> -•/ F--1 nll.tt'� 2❑Irriealion 5❑Municipal 8❑Cmmmercial <br /> >3s - FORM ATION LOG COLOR HARDNESS Of FROM TO <br /> FORMATION l❑Test Well 6❑Air Conditioning 9❑ <br /> 7.CASING HEIGHT:Above/Below HOLE DIAM <br /> i Ee I❑Black 40 Threaded <br /> 20Gaw. 51:1Welded Surface ft. <br /> 30 Plasfi�_. 6❑ Drive Shoe? Yes_ No_ <br /> m.to fl. Weight lbs./ft. in.to_ft. <br /> in.to ft. Weight lbs./fl. _in.loft. <br /> into fl. Weight lbs./ft. in.to_ft, <br /> 8.SCREEN , <br /> open ole <br /> Make from fl.to ft. <br /> f Type Dia. <br /> Slot/Gauze Length <br /> FITTINGS. <br /> Set between ft.and ft. <br /> ft.and A. <br /> 9.STATIC WATER LEVEL <br /> fl.❑below ❑above Date Measured <br /> "— "---- - land surface <br /> 10. PUMPING LEVEL(below land surface) <br /> fl.after h-pumping g.p.m. <br /> fl.after his.pumping g.p.m. <br /> 11.WELLHEAD COMPLETION <br /> 1n PW-s adapter,manufacturer - model <br /> 20 thi—ent ff., J❑Al least 12"above grade <br /> 12.WELL GROUTED? <br /> ❑Yes ❑No <br /> IQ Neat C'emcnl 20Benlonite J❑ <br /> Grout material Irom t. ft,Cu.Yds. <br /> 13.NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion". YesE No❑ <br /> 14. PUMP <br />.��. Dale installed ❑Not installed <br /> Manufacture!',Name <br /> Model Number HP Volts <br /> Length of drop pipe ft.capacity g.p.m. <br /> Material of drop pipe <br /> Type: 30 L.S.Turbine 5❑1feclprocaling <br /> 20jet 4❑C'ent,,f,"l 6❑ <br /> Use n second sheet.if needed 16.WATER WELL CONTRACTOR'S CERTIFICATION <br /> .REMARKS,ELEVATION,SOURCE OF DATA.etc. This well was drilled under my jurisdiction and this report is true to <br /> F the best of my knowledge and belief. <br /> A <br /> Licensee Business Name License No. <br /> Address <br /> Signed , Date <br /> Authorized Repr<eid.twe <br /> w <br /> Date <br /> Name of Driller <br /> LOCAL COPY 4 0 5 0 6 3 7/7630M <br /> 7/78 30M <br /> 7/78 30M <br /> ti E-01205-Ot 2/82 lOM <br />