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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> I.LOCATION OF WELL WATER WELL RECORD MINNESOTA UNIQUE WELL NO. �] <br /> County Name for Wafer Sample r <br /> Minnesota Statutes 156A.01-.08 <br /> 1115 <br /> Township Name •L�� Township Number Range Number Section No. Frraac�tiion gyp 4.WELL DEPTH(completed) D�Completion�p �{�_�� <br /> 11iii o W 33 AA / W ice'/ h. 10-30-'FV <br /> Numerical Street Address and City of Well Location or Distance Jism Road Intersectiob. 57DRILLING METHOD '^ <br /> 2725 v. ta Blvd.' Lmg Luba- M 55M ❑Cable"fool ❑Reverse ❑Driven ❑Dug <br /> Show exact location of well in section'grid with-X.- ^7 Sketch map of well location. ❑Hollow Rod ❑Air ❑Bored ❑ ____ <br /> N <br /> I t t Addition Name -. M•. JERotary ❑Jetted JtPower Auger <br /> -r'-�- - -1_ 6-DRILLING FLUID <br /> Block Numb <br /> W E Number we � -�y' 7wUSE w <br /> t <br /> f- <br /> ❑Domestic Xonitoring ❑Heat Pum <br /> pT ❑Industry <br /> mi. Lot Number <br /> 0 Irrigation 0 Public <br /> ❑Test Well �❑Municipal ❑Commercial <br /> ❑Air Conditioning ❑ <br /> �—I mile 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address lack HEIGHT:Above2 <br /> _ ❑Threaded <br /> 19. Surface- ft. <br />�., indg¢ o�� a� t $1 . -p Galv. YWelded <br /> 276 • l Drive Shoe? Yes—No-X <br /> VCT Com#fial.� I=& 1� Lake, P- 55356 b Plastic ❑ p � <br /> 2_m.to 4 ft. Weigh lbs./ft. flan t,11ft. <br /> 3. FORMATION LOG COLOK HARDNESS OF FROM TU in.to ft. Weight lbs./ft. Win. tort. <br /> FORMATION <br /> in.to ft. Weight lbs./ft. _in. tort. <br /> rrbp sail fill $l&* 0 3 9.SCREEN Or�open hole <br /> Make J7Wm-10i1 from ft.to., tt. <br /> q >f <br /> Clay Green 3 14 Type $bmf . Diam.' 2 <br /> Slot/Gauze Length IB - <br /> " FITTINGS: <br /> *t between 4 ft.and 14 ft. <br /> 10. STATJ WATER LEVEL q <br /> ftX below ❑above ,,: Date Measured <br /> land surface <br /> 11. PUMPING LEVEL(below land surface) <br /> .. ft.after hrs.pypiping 2 g.p.m. <br /> ft.after hrs.pumping g.p.m. <br /> 12.HEAD WELL COMPLETION <br /> ❑Pitless adapter manufacturer Model <br /> "❑Basement,offset JtAt least 12"aboveground 4 <br /> O Plastic casing protection <br /> 13.WELL GROUTED? ZYes ❑No <br /> ...X.Neal Cement <br /> �,❑�Bentonite ❑ <br /> Grout material I �y,""".'�- from 0 to—_3—_ft.cu.yds <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? ❑Yes RNo <br /> 15. PUMP <br /> Date installed KNot installed <br /> Manufacturer's name - <br /> Model number HP Volts <br /> Length of drop pipe ft. Capacity <br /> Material of drop pipe -- <br /> Type: ❑Submersible ❑L.S.Turbine 0 Reciprocating <br /> ❑Jet ❑Centrifugal 0 - <br /> 16. ABANDONED WELLS <br /> Unused well on property? ❑Yes ANo <br /> Use a second sheet,iJ needed fed ❑ 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. <br /> Stevens Wel I Drii l 1 m Co. 27194 <br /> Lirensee Business Name License No. <br /> Address 6240Plain, ...1T rr 9 <br /> -' " <br /> 1-23-91 <br /> X13 ned tt <br /> Date <br /> n..,,,� Authorized Representuliue� <br /> �l�7 J Date 1—Z-3-71 <br /> Na me of Driller <br /> 5/74 30M <br /> LOCAL COPY 1471115 7/7830M <br /> 7/78 0M <br /> 1 <br /> HE-01205-03(Rev.9/88) 2/82 IoM <br />