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A - STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1.LOCA1. WATER WELL RECORD MINNESOTA UNIQUE WELL NO. A 4 <br /> Canty Nam. i Minnesota Statutes 156A.01-.08 (,-�/or Wafer Sample 1 CI /6 6'l09 <br /> Township Name, Township Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> 1' or or ,/� .: ,,'/ „4,:1/4� <br /> ._t' S H, ”' a".-, ,; k 1,4;,. ft. ., r.t'y cv; <br /> Distance and Direction from Road Intersection or Street Address and City of Well Location 5.DRILLING METHOD <br /> 10 Cable tool 40 Reverse 70 Driven 100 Dug <br /> Show exact location of well in section grid with"X." Sketch map of well location. 20 Hollow rod 50 Air 80 Bored 110 <br /> N <br /> 1 t i Addition Names j .. S: 30 Rotary 60 Jetted 90 Power gauger <br /> t ' ' 6.DRILLING FLUID <br /> IX <br /> �__�_ Block Number � <br /> W 4* ' t E 7.USE <br /> l6Domestic 40 Monitoring 80 Heat Pump <br /> I ' Lot Number 20 Irrigation 50 Public 90 Industry <br /> fe mt. 30 Test Well 60 Municipal 100 Commercial <br /> - —r 1 70 Air Conditioning 110 _ <br /> I mile---♦ 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME HEIGHT:Above/Below <br /> t" � 1t]Black ,40 Threaded <br /> k,3' ake 3.Lv.2.ilaf..Yi ct5'. 20Galy. 5❑Welded Surface ft. <br /> esDrive Shoe? YesNo__ <br /> Address <br /> 33 BlAkti. Lake <br /> g:ireLt 30 Plastic 60 <br /> 0• 1. " Or(Jnofi Long Lake, MN. in.[o <br /> i ; c ft. Weight t .9_ <br /> lbs./ft. _gin. to_ft. <br /> _ <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight lbs./ft. —gin. to_ft. <br /> FORMATION <br /> in.to ft. Weight lbs./ft. _in. to-1t. <br /> ‘...:1.:::--:: `>'-+ 9.SCREEN Or open hole <br /> -- from ft.to. ft. <br /> tt Make ''"i , _, <br /> - <br /> rf�; J.::.I Type Z�, .. .( �_+i Dis. sE <br /> Slot/Gauze • -- Lengt f <br /> FITTINGS: <br /> - Set between - •- ft.and 1 ` , ft. <br /> 10. STATIC WATER LEVEL <br /> --1- ft.l'}below ❑above Date Measured r -=i:-�-+`r <br /> land surface <br /> 11. PUMPING LEVEL(below land surface) <br /> = ft.after • hrs.pumping • _ g.p.m. <br /> ..._ ft.after _- - hrs.pumping g.p.m. <br /> 12. HEAD WELL COMPLETION <br /> --)IE .7 1f7;Pitless adapter.manufacturer ;?[r-(z -,_^_ _' model <br /> �\/���+j M 20 Basement offset 3f,3`At least 12"above ground <br /> M� V 40 Plastic casing protection <br /> 13.WELL GROUTED? <br /> ZO Yes ❑No <br /> 1❑Neat Cement 20 Bentonite 10 '-r t�•ai_ pa,-•';r t''-i. f I <br /> Grout material from to ft.cu.yds. <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? l3 Yes 0 No <br /> 15. PUMP <br /> Date installed ---t?._ 0 Not installed <br /> Manufacturer's name - <br /> Model number HP - Volts - <br /> Length of drop pipe ft. capacity - g.p.m. <br /> Material of drop pipe '-' ...,f.,-•••:-.•!•-; <br /> o - 1 <br /> Type:1C{Submersible 30 L.S.Turbine 50 Reciprocating <br /> 20Jet 40 Centrifugal 60 <br /> 16. EXISTING WELLS <br /> Unused well on property? 0 Yes ❑LNo <br /> Use a second sheet,i/needed Abandoned 0 Permanent 0 Temporary 0 Not sealed <br /> 17. REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> • 18.WATER WELL CONTRACTORS CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. <br /> ,""`"_4,1 ,., '-','"'1'.:",:f K t•+i.vY 7 L �t I&n `.+, /7..;,--, - <br /> ..,.......�. a <br /> Wire`s-ue"tJi�sInecs`�7�ame `- "F Liceitu Ao`. — <br /> Address �.-. 1:..4 :. y 8 ..E1.:1. I.': <br /> Signed - -Dater' <br /> Authorized Representative - ` <br /> __—. • Date - <br /> Name of Driller _ {" <br /> 4410667/76� <br /> LOCAL COPY 7/76 <br /> HE-01205-(12(Rev.10/851 <br />