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_�ATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> nly1: - - Fni j7i;1 WELL RECORD 526431 <br /> � Minnesota Statutes Chapter 1031 <br /> Township Name 7wnship No. Range No. Section No. Fractipnt WELL DEPTH(completed) R Date Work Completed <br /> Numerical 'treet Address and City of Well Location or Fire Number DRILLING METHOD <br /> A�-. ❑ Cable Tool ❑ Driven ❑ Du <br /> <`v C'. a LertC+�`xi Ilk co i";3_Cin � A� ❑ t <br /> ❑ 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 .;3.:.:. <br /> I c ' <br /> c � <br /> c c t USE C3"Domestic ❑ Monitoring ❑ Heating/Cooling <br /> ❑ Industry/Commercial <br /> yy ; I E ❑ Irrigation ❑ Public <br /> ❑ Test Well ❑ Dewatering Remedial <br /> I ; T Ci- 0 <br /> f-mi. X CASING Drive Shoe? RI Yes [-1NoHOLE DIAM. <br /> --t- <br /> c �- — —r- +Steel 1:1 Threaded ❑ Welded <br /> �— •� ❑ Plastic ❑ <br /> /Mil, K i� � jet? <br /> liJA <br /> CASING DIAMETER Trish <br /> WEIGH <br /> PROPERTY OWNER'S NAME " "Z- IL, <br /> yy n,�, <br /> i1 Mrt -y in.to ft. lbs./ff. in.to_,. <br /> in,to ft. lbs./ft. J7(in.to <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make r" x^ Steel from ft.to ft. <br /> Type r Diam. <br /> Slot/Gauze 2C,0 Length <br /> Set between j`"ff.and ft. FITTINGS: <br /> STATICATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF <br /> MATERIAL FROM TO �' ft. CFbelow El above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> ul a ! t � t ft. after hrs.pumping 9— <br /> p.m-WELL HEAD COMPLETION <br /> c;t •+ ❑-itless adapter manufacturer FYl 4.k. cr � Model <br /> ❑ Casing Protection [1:12 in.above grade <br /> Lit, : f•�t .;j+ GROUTING INFORMATION <br /> Well grouted? ❑ Yes �b No <br /> // Grout Material 71 Neat cement ❑ Bentonite <br /> a�,TIC i r;%41 t I { I <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? EKYes ❑ No <br /> PUMP WA <br /> ❑ Not installed Date installed [�� <br /> Manufacturer's name H(MkIl & — Sta-Rlte , <br /> Model number HP 1�4 _Volts <br /> Length of drop pipe 146 ft. Capacity <br /> Pressure Tank Capacity 1 EC.UNEKS <br /> Type: Qp,Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> ti> <br /> Does property have any not in use and not sealed well(s)? t?Yes ❑ No <br /> WELL CONTRACTOR CERTIFICATION <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 /> lx,A\. AVAXj1A Wk',, 11*11,I,1Uj. .iNC. G!i'i r: <br /> Use a second sheet,it needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> I-'.i:.. i`iC.l`e•;:ti ii-;i 5-2'6-93 <br /> Name of Driller Date <br /> LOCAL COPY 15264311 HE-01205-04(Rev.5/92) <br />