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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1.LOCATION OF WEL WATER WELL RECORD YINNESOTA UNIQUE WELL NO. 7 i 114 <br /> County Name /or Water Sample <br /> Haulepin Minnesota Statutes 156A.01..08 <br /> Township Name Township Number Range Number Section ction No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> Or MR o Z3iaT or 33 Nd Staff NEI/, 14 ft. 1(}_2'9-90 <br /> Numerical Street Address <br /> and City of Well Location or Distance <br /> �Tfrom <br /> LL,Road intersection. �t 5.-DRILLING METHOD <br /> 2725 W. Way=t€i Blvd.. Long Lake, M 55356 ❑Cable Tool ❑Reverse ❑Driven ❑Dug <br /> Show exact location of well in section grid with"X." Sketch map of well location- ❑Hollow Rod ❑Air ❑Bored ❑ <br /> N YY�� <br /> i i Addition Name i Mkotary ❑Jetted APower Auger <br /> --r---�- -1 -1- <br /> � 6.DRILLING FLUID <br /> t t Block Number <br /> W ' I E Well Y aw - <br /> ' T " <br /> -1- --- -- -_ I ❑Domestic �Mom-toring ❑Heat Pump <br /> I <br /> Lot Number ❑Irrigation ❑Public ❑Industry <br /> *+r <br /> ' - ❑Test Well ❑Municipal ❑Commercial <br /> --t- -�- -; -r- I ❑Air Conditioning ❑ <br /> 1 <br /> 1 I —� "F 8.CASING HOLE DIAM. <br /> mile <br /> HEIGHT:Above/ <br /> ❑Threaded <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address KBlack <br /> indicated above' Surface 2 ft. <br /> a capitiat rnc. 2765 W., -WTYla't a J.ZVd. 't Plastic ❑ Drive Shoe? Yes_No_X p p <br /> 1CM Lake, ';•N 5 p <br /> 55 in.to 4 ft. Weight lbs./ft. _n. to-14it. <br /> 3. FORMATION LOG COLORHARDNESS OFFORMATION FROM TO in.to t. <br /> it. Weight lbs./(t.� —in. to <br /> in.to ft. Weight lbs./ft. Win. tort. <br /> TU;? sol & fill BLICk @ 3 s.SCREENOr open hole <br /> Make <br /> from-ft.to. ft. <br /> �.a <br /> Clay a'eM 3 14 Iylx Si.inai ew Stere] w Dfam. <br /> 109 <br /> Slut/Gauze Length FITTINGS: <br /> 4t between 4 ft.and �� ft. <br /> 10. STfC JIV IR LEVEL �! <br /> jjr fLabelow ❑above Date Measured <br /> land surface <br /> 11. PUMPING LEVEL(below land surface) <br /> ft.after 1 hrs.pumping 2 g.p.m. <br /> ft.after hrs.pumping -__— g.p.m. <br /> 12. HEAD WELL COMPLETION <br /> ❑Pitless adapter manufacturer Model <br /> .10 Basement,offset JtAt least 12"aboveground <br /> ❑Plastic casing protection <br /> 11 WELL GROUTED? KYes ❑No <br /> Neat Cement ❑Bentonite ❑ 1 bw <br /> Grout material from ID to- ft.cu.yds.-- <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? ❑Yes XNo <br /> 15. PUMP <br /> Date installed $Not installed <br /> w <br /> Manufacturer's name <br /> Model number HP Volts __. <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Material of drop pipe <br /> Type: ❑Submersible ❑L.S.Turbine ❑Reciprocating <br /> ❑Jet ❑Centrifugal ❑ -- - <br /> 16.ABANDONED WELLS <br /> Unused well on property? ❑Yes 'A No <br /> Use a second sheet,iJ needed homed ❑ 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. y� <br /> s Td1 al Deli um Co. 27194 <br /> Licensee Business Name License No. <br /> Address 6240 . 12 liaple plain 144 55359 <br /> Signed Date l-�: 91 <br /> Authorized Representative <br /> Randv Jchronn Date1^ �y <br /> Name of Driller <br /> 6/74 30M <br /> LOCAL COPY 1471114 7/7830M <br /> 7/78 30M <br /> HE-01205-03(Rev.9/88) 2/82 10M <br />