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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1.LOCATION OF WEL WATER WELL RECORD MINNESOTA UNIQUE WELL NO. A 4���I <br /> GCounty Name ... for Water Sample <br /> - Minnesota Statutes 156A.01.08 <br /> Township Neje Township Number I Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> �# ,ttcj 117 23 or 03 NE 'IN '/ 148' ft 5--22-91 <br /> Numerical Street Address and City of Well Location or Distance from Road Intersection. 5.DRILLING METHOD <br /> Jyj <br /> 2165 Water-tow Pond' �y w r Nn• ❑Cable'fool ❑Reverse 11 Dug -1 <br /> Show exact location of well in section grid with"X.- Sketch m of well location. ❑Hollow Rod ❑Air UlIQ� •j� <br /> -N - u <br /> t t UU <br /> Addition Name rotary ❑Jetted ❑Power Auger <br /> j 6.DRILLING FLUID <br /> •-i_ _ _ '_ .�_ Block Number _ F 7. USE <br /> W E <br /> Winneslic ❑Monitoring ��� �np <br /> Lot Number ❑Irrigation ❑Public ❑Indusy <br /> 1991 <br /> mi. <br /> t � � ❑Test Well 47 Municipal � ❑Commercial <br /> r- <br /> --�- �- - - ❑Air Conditioning ❑ - <br /> r <br /> mile 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address ❑Black ❑Threaded HEIGHT:Above/Below <br /> %!L1* J.,y1.C.tfiAn it. <br /> . ❑Galy. ❑Welded <br /> Surface <br /> Pbbert Kantor Hemetwnpx 2165 Watert` n Road Drive Shoe? Yes No— <br /> w <br /> in.to 144 it. Weight lbs,/ft. in. [o4lSdt. <br /> 3. FORMATION LOG COLOR HARDNESS OF <br /> FORMATION FROM TO in.to Wi <br /> it. Weight lbs./it. n. tort. <br /> in.to ft. Weight lbs./ft. in. to---Jt. <br /> Uav (} s 9.SCREEN Or open hole <br /> Make Johoson <br /> from ft.to. ft. <br /> Sand 140 . 148 Type Stasi nless, Steel Dfam. 4" <br /> Slot/Gauze Length <br /> FI INGS: <br /> Set between 1 Qd ft.and 148 ft. <br /> 10.STA WATER LEVEL <br /> ft.X.I. ❑above Date Measured -•"' `��'�� <br /> land surface <br /> 11.PUMPING LEVEL(below land surface) <br /> 70 ft.after 4 hrs.pumping *" 9-P in. <br /> ft.after hrs.pumping g.p.m. <br /> 12.HEAD WELL COMPLETION <br /> *itless adapter manufacturer kbite WaterModel <br /> '❑Basement,offset IXAt least 12"above ground <br /> ❑Plastic casing protection <br /> 133..WELL GROUTED? )D Yes ❑No <br /> XNeat Cement ❑Bentonite ❑ 30Grout material from 30 to 6 ft.cu.yds. <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION • <br /> feet direction type <br /> Well disinfected upon completion? JKYes ❑No <br /> 15. PUMP <br /> Date installed 6-11-91 ❑Not installed <br /> Manufacturer's name (;nlndfCS <br /> Model number HP 14 Volts ..1) <br /> Length of drop pipe 105 .., fl. Capacity 20 g.p.m. <br /> Material of drop pipe I" �+Vq�y <br /> • <br /> Type: XSubmersible ❑L.S.Turbine ❑Reciprocating <br /> ❑Jet ❑Centrifugal ❑ <br /> 16. ABANDONED WELLS <br /> Unused well on property? ❑Yes [Ao <br /> Use a second sheet,if needed Sealed ❑ Permanent ❑ Temporary ❑ Not sealed <br /> 17. REMARKS,ELEVATION,SOURCE OF DATA,etc. <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. yyyy i�my++.. <br /> LlA� b� !�TT ER�t'M CO.,t 1W. L 7r�p <br /> 172.: <br /> �Licensee Business Name License No. <br /> Addressr <br /> Si Date 5-22-01 <br /> Authorized Repr fal <br /> �t ftie <br /> I F, P. Xcfthm Date 5-•22--91 <br /> Name of Di ler <br /> 5/74 30M <br /> LOCAL COPY 1475726 7/76�I <br /> HE-01205-03(Rev.9/88) 2/82 10M <br />