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STATE OF'MINNESOTA DFPARTMENTOI HEALTH <br /> I. LOCATION 01 WE LL <br /> MINNESOTA <br /> WELL NO. <br /> camr Na- WATER WELL RECORD for wre.sample <br /> Hance; n SNeI5M1A.(II (IX 403782 1 <br /> Twnship Name <br /> Township Number Han{c Numher Serlion No I I...lion 3. PROPERTY OWNERS NAME <br /> Orow 117n 23w or Gj=1T <br /> Dnlance and Daeclipo from Road Inlrrsee lions or Street Address and Cil,.(Well Location Add a 1030 ioWtava <br /> Lan Lake. MW 5356 <br /> ------Show exa.l location of well in section grid with"%." Sketch map of well Iocalion. 4. WELL DEPTH(completed) Date of Completion <br /> N Addition Name 13°' Imo ' 65 <br /> .-ti - ft. <br /> I❑Cable totd 40 Re— 70 06— 100Dag <br /> W - - �- - E <br /> + <br /> 1,11-1,Number <br /> TTz❑Hnnnw rod s❑Air a❑Bnree 110 <br /> 3 Rnwry 60Jelted 9❑Power Auger, <br /> ! Lot Numher 6. USE <br /> __ _-- <br /> S <br /> __ <br /> ILOOnmesua 40Puhlic Supply 70 Industry <br /> �l nrii. 70Irrigation 50Municipal 80C'ommcrcial <br /> 3. FORMATION LOG COLOR HA R DN FSS OF FROM TO <br /> FORMATION 30Test Well 613Air C'nnditioning 9❑ <br /> 7.CASING HEIGHT: Above/Below HOLE DIAM <br /> top oil ID 2 101410141-1,l4❑Threaded <br /> '�Y��` � �r y4 306a1y. 5❑Welded Surface ft. <br /> ye� clay 2 14 3EXPlastic 613 Drive Shoe? Yea_ No 132 <br /> yy` 4 in.toYft ft. Weight �_Ibs./ft. —in.to—ft. <br /> I-my r sand 14 4 in.to ft. Weight tbs./n. —in.loft. <br /> In.to rt. Weight lbs./ft. n.t.—ft. <br /> blues clay 4l 65 _ 8.SCREEN ropen hole <br /> Make J4—N1saRf1111 from <br /> fl.to <br /> boulder Gite—pk b 65 7 Type at. heel Dia. 4• ft. <br /> f <br /> Slnl/Gauze 15 Length <br /> � 28 FITTINGS: <br /> 67 Set between ft.and 132 U. <br /> blueclay—redbblack9x��� t f�f <br /> ft.and ft. <br /> 9.STATIC WAT'R LEVEL <br /> u` oII� gravel-blueg fl.❑below ❑above Dale Measured 1-10 <br /> land surface <br /> 100 132 10.PUMPING LEVEL(below land surface) <br /> rt.aper ors.vamping g.p.m. <br /> ft.after hrs.pumping Spot- <br /> 11.WELL HEAD COMPLETION <br /> =Pairs.,adapter,manufacturer model <br /> z❑Basemen)offset 3❑At least 12"above grade <br /> 12.WELL GROUTED? �gNp <br /> ❑Yes MN. <br /> — 1❑Neat C'ero n ]❑Bentonite 30 <br /> Grout material from to ft.Cu.Yds. <br /> 13.NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> 'a direction type <br /> Well disinfected upon com plellon? YC No❑ <br /> �� � •�, 14. PUMP <br /> Lj Dale installed .„ ❑Not installed <br /> Manufactu V.Name nf fltrkat <br /> a <br /> Model Number HY � Volts�_ <br /> Length of drop pipe CJ,7 ft.capacity 12 g.p.m. <br /> 1 Material of drop Alpe <br /> zaly <br /> Type: *1S.1mu—ihle 30 L.S.Turbine 50 Reciprocating <br /> 201et 4❑C'entrifugal 60 <br /> Use a second sheet,if needed 16.WATER WELL CONTRACTOR'S CERTIFICATION <br /> 15.REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> This well was drilled under my jurisdiction and This report is true to <br /> the best of my knowledge and belief. <br /> Sie53'"n Well ro. 27194 <br /> Licensee B-mm Name License No. <br /> 6240 fty 12 v% Maple Plain, M1 <br /> Address <br /> Signed Date I,..1 ri...9 <br /> Authorized Representative <br /> Richard Stevens Date <br /> Name of Driller <br /> LOCAL COPY 1403782 7/7630M <br /> 78 30M <br /> HE-01205-01 2/82 10M - <br />