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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1.LOCATION OF WELLI MINNESOTA UNIQUE WELL NO. V <br /> County Name WATER WELL RECORD <br /> llemepip Minnesota Statutes 156A.01.08 for Water Sample <br /> 478352 <br /> Township Name Township Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Dale of Completion <br /> t3lror�cl 1175 23W W 7 SK 1!�T SE / 2X5 rt. :Z/32/91 <br /> Numerical Street Address and City of Well Location or Distance from Road Intersection. 5. DRILLING METH015 <br /> 1360 Vine Place Mound, M 55364 ❑CableTool ❑Reverse ❑Driven ❑Dug <br /> Show exact location of well in section grid with'X- ��Li Sketch map of well location. ❑Hollow kod ❑Air ❑Bored ❑ <br /> N <br /> 1 t t Addition Name SkRotary ❑Jetted ❑Power Auger <br /> ��DIj�LLING FLUID <br /> }MaT�it._' _ <br /> W i Block Number <br /> E 7.USE <br /> t 2 Domestic ❑Monitoring ❑Heat Pump <br /> 1 1 t Lot Number ❑Irrigation O Public ❑Industry <br /> t ❑Test Well ❑Municipal ❑Commercial <br /> —�— — —�- I ❑Air Conditioning ❑ <br /> 1 mile's 1 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address ❑Black ❑Threaded HEIGHT:Above/Below <br /> indicated above. Surface ft. <br /> Earl MmwoOB ❑Galy. ❑Welded <br /> Drive Shoe? Yes—Nom <br /> QVIastic ❑ <br /> 4 in.to n ft. Weight 1_9lbs./ft. n. UGLL(t. <br /> 3. FORMATION LOG COLOR HARDNESS OF <br /> FORMATION FROM TO in.to ft. Weight lbs./(t. in. to---Jt. <br /> in.to ft. Weight- lbs./(t. in. to—Jt. <br /> Topsoil Black, Q 1 9.SCREEN Or'open hole <br /> T from ft.to. It, <br /> clay <br /> ,-w ��y Make J� � ,{ <br /> Clay Yellow 1 30 Type C Vl. t Diam. +3 111. { l <br /> Slot/Gauze 16 slot Length 5 r..:a�.lft- <br /> �/� � 21� F}TTING�� <br /> Clay uCw -3Q �2 21 Set between�.l\L ft.and�.i.�ft. j'� <br /> B1Lzc 10. STATIC (ASTER LEVEL <br /> lay AgraVel y) in 42 152v ft.X below ❑above Date Measured? 7 <br /> ,��., land surface <br /> ',1,^, FCCti,ld.l.l:iii 11.PUMPING LEVEL(below land surface) '^ <br /> Clay/gravel rav l s fl.after hrs.pumping j,y0+ g.p.m. <br /> lite Y ft.after hrs.pumping g.p.m. <br /> Gravel brawn 12.HEAD WELL COMPLETION L�.�., <br /> XPitless adapter manufacturer_i7IA Model <br /> '❑Basement,offset ❑At least 12"above ground <br /> ❑Plastic casing protection <br /> 13.WELL GROUTED? 2]Yes ❑No <br /> .�Neat Cement ❑Bentonite ❑ ��y <br /> Grout material from 0 to M ft.cu.yds.— <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? *Yes ❑No <br /> 15. PUMP <br /> Date installed ❑Not installed <br /> Manufacturer's name <br /> Model numberHPHP-1/2-Volts 7*40 <br /> ppryry <br /> Length of drop pipe G1�/ ft. Capacity g.p.m. <br /> Material of droppipe <br /> P <br /> Type:$Submersible ❑L.S.Turbine ❑Reciprocating <br /> ❑Jet ❑Centrifugal ❑ <br /> 16. ABANDONED WELLS '-tP <br /> Unused well on property? IiYes ❑No .; <br /> Use a second sheet,i/needed Sealed Permanent ❑ Temporary ❑ Not sealed <br /> 17.REMARKS,ELEVATION,SOURCE OF DATA,etc. 'S <br /> 18.WATER WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. <br /> GtlMimi WPl1Drillim ()p_ 27L94 <br /> icensee Business Name License Na. <br /> Address 6240 1 Q plain_ M 1, 59 <br /> Signed 1 � / I. _ Date713 891 <br /> Authorized WppreVntatlue <br /> Mike]R.Iir xii DaleF tt1", <br /> Name o(Drtlfer <br /> LOCAL COPY T4783521 5/7430M <br /> 7/76 30M <br /> 7/7830M <br /> HE-01205-03(Rev.9/88) 2182 IoM <br />