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STATE OF MINNESOTA - MINNESOTA UNIQUE WELL NO. <br /> DEP8RT!ENT OF HEALTH 127317 <br /> WATER WELL RECORD for Water Sample <br /> 1. LOCATION OF WELL, Minnesota Statutes 156A.01-.08 <br /> CountyDeme Fraction Section Number Twnship Number Range Number 3. PROPERTY OWNER'S NAME <br /> t <br /> 1111101101. illtint n in 23 <br /> f/Distance and Direction from Road Intersections or Street Address and City of Well Location- <br /> Show exact location of well in section grid with "X." Sketch map of well location. 4. WELL DEPTH (completed Date of Completion <br /> , N 1 24 ft. 3 <br /> I 1 1 1 5 10 Cable tool 40 Reverse 70 Driven 100 Dug <br /> W — E <br /> p 20 Hollow rod 50 Air 80 Bored 110 <br /> -t- -' -�- `- }mt. <br /> Tina ITEM _kta uun 71/Rotary 60 Jetted 9OPwer Auger <br /> I <br /> UUU 77 t�3 ����d/// <br /> ) ' 6. USE <br /> Rim <br /> s <br /> IFaLED 1Domeatic 4OPublic Supply 71_1lndustry <br /> 1--------1 male 20 Irrigation 50 Air Conditioning RO Commercial <br /> 2. FORMATION LOG COLOR HARDNESS OF FROM- TO <br /> FORMATION 30 Test Well 60 <br /> 7. CASING I HEIGHT: Above/Below <br /> DIAM. <br /> Threaded130 1 Welded 03 Surface ft. <br /> *wit Sod 10 200 4 Black - 2atm, Galy. 0 <br /> --41141W <br /> in. to ft. depth Weight sak.2 200 200 <br /> in. to ft. depth <br /> io. to - ft. depth Drive Shoe? Yee JE No_ <br /> 78. SCREEN Or open hole <br /> Make ! from ft. to ft. <br /> Type f ...'._. i✓' Dia. ' <br /> Slot/Gauze Length <br /> FITTINGS: <br /> Set between rat ft. and in ft. <br /> ft. and Et. <br /> ft. and ft. <br /> 9. STATIC WATER LEVEL <br /> Allffft. below ['above Dnte Measured <br /> land surface <br /> 10. PUMPING LEVEL (below land surface)WO n' <br /> ft. after 4 hrs. pumping g.p.m. <br /> _. ft. after bra. pumping g.p.m• <br /> E V}I _ _ _, U. WELL HEAD COMPLETION <br /> . ` s •" WIPStleee adapter 20Basement offset 3❑At least 12" above <br /> grade <br /> �/�/� 12. Well grouted? <br /> CT - 4 f Eites Oso Cu. Yds. <br /> `���vVV 1❑Neat cement 2❑Bentonite /102211010440411931—3 f' <br /> Depth: from ft. to ft. <br /> 1TY OF O I from ft. to ft. <br /> 13. Nearest source of possible contamination SOU <br /> feet direction type <br /> Well disinfected upon completion? Yes ill No 0 <br /> 14. PUMP <br /> Date installed <br /> _ El Not installed <br /> Manufacturer's Name <br /> Model Number HP volts <br /> _. Length of drop pipe 12$ ft. capacityg.p.m. <br /> Material of drop piper 12 <br /> _____ --_. — Type: 1XSubmersible 30 L.S. Turbine 50 Reciprocating <br /> 20 Jet 40 Centrifugal 60 <br /> 16. WATER WELL CONTRACTOR'S CERTIFICATION <br /> This well vas drilled under my jurisdiction and this report is true to <br /> _ —- the best of a5'knowledge and belief. <br /> Use a second cheat, if needed. *,y 1.004. 1111 <br /> 15. REMARKS,ELEVATION, SOURCE OF DATA, etc. Licensee Business Nane ?? .4LL�e'rcnse No. <br /> Address # li . '��3:ffia <br /> Signe `if'/—e..)� 'e to-; - Date 1$4411. . <br /> r� Authorized Representative <br /> — ter► <br /> LOCAL COPY Name of Driller 7/74 30M <br />