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� <br /> - STATF:()V-MINN1�:1()TA �E�.I'AHTMlNTOI�Ht:AITH <br /> 1. ln('ATI()N()I�WF�LL Q <br /> c�����r N•�,.•� � W A T E R W E L L R E C 0 R 0 �IINNESOTA UN/ ue wer.c No. <br /> � ,.Wor�,samP,� 4 0 3 7 6�� <br /> Minnetofa S!e lultl/SM1 A.fl/�.f�N <br /> T��wnxhip Name T�wnship Numher Nan{e Numher Secllnn N�. I�r���ti��n J. YROYk;RTY OWNER5 NAMt <br /> N f �, �, y, <br /> Q'.L"{3�b �.�.� � s` � '�w $ �' � �#' �4►'L't��Y't � <br /> u�.r��e,�a n� �c���rt����RnaJ InlrrSrcliuns ut Slrcel AJJrtss and C11y o(WNI Loctlion naa.e:s <br /> 1.�Q �da31" r A 3� t� � <br /> Sl+ow ea�c�li�<��ion of well in src�iun gri�wilh"X." Sketc�map of well Incation. 4.Wk:LL DEPTH c <br /> N (ompleted) Date of Complelion <br /> � ' AJJi�i�m Name �,��)p+y <br /> _ L' '�' ' -'_1- - 4v-Y fl. ��� <br /> � � I i S. <br /> r i❑e�nir��,�a a❑Ke.e�u ��n,�.�� io❑o�g <br /> N - . - - �- - <br /> , , + � r G tll��ck NumAn <br /> • a :❑H�m,�w.,,a sOn�, e❑e�,«a ii❑ <br /> - ' '� '- '� ��M.. J�K"t�rY 6❑letled 9�Yow<r Auger <br /> ' ' ' � Lo1 NumAer 6. USF. . <br /> _'i_ ' __'' _- _'',__ < , . <br /> "akilo��mrv�� a❑v�nro s�vvq a��oa�,vr <br /> $ <br /> �1�1LZt-� 2�Irrigu�ii�n 5❑Municipal B�C�mmercial <br /> I. FONMATIONL04 C'OLOH HAH11Nf'SSOF FHOM TO <br /> FOHMATIUN J�Te�I Well 6OAir(lindilinnin` 9� <br /> 7. CASING HEIGHT: Above/Below HOLE DIAM <br /> '�� '�� $ � � � I❑Black a❑T�rraded <br /> 2�(:alv. SOWelded Surfatt ft. <br /> '�'� �++�� � � .i� �]Plastic 6� Drive Shoe? Yes_ No� <br /> � �in.to ��� ft. Weighl�»� Iba./tt. �In.t����ft. <br /> ��� ��� � . �� ��✓ in.to ft. WeiBht Ihs./(t. —in.[o_It. <br /> In.fo fl. WeiRht Iba./fl. _in.Io_(t. <br /> �� ��V �� �^ 8. SCRk:F;N ��� ropen ole <br /> ,J trom (t.�o ft. <br /> Make <br /> ' 32+�f� � �}�'1 �j3� TYVe � Dii. <br /> Lti.L i�. wJ ..f J' <br /> � Slnt/Gauze �� Leng�h �t <br /> ��j� F'ITTINGS: <br /> e" Sel between ��L ft.and ��(t. <br /> #��.'rt� ��Y. & 1� C �'� �.�t� <br /> «.a�a ��. <br /> /� 9.STATIC WATk'.R LEVk:L <br /> � `� � � 6� fl.�helnw ❑ahove DeleMeasurcd �+��� <br /> " - — — land surface <br /> �� ��� �1�� �t..� I0. VUMNING LEV F,L(Gelow land surface) <br /> �f +T 4 J�yy <br /> ft.af�er �rs.Oumpin6 1L7�.1 B�V�m� <br /> ��� �� �� ff.affer hrs.pumpin8 B.p.m. <br /> 11.WELLHEAUCOMYLETION y�!8�� <br /> �Q Pitless aCap[er,manufac[urer ���r�RS����tlel <br /> `��' ���� �� ,�� 3❑dasemenl offsel 3��+��east 12"above gretle <br /> 12.WELL GROUTED? <br /> ❑Vr� yONo <br /> — I�Neal('emenl l�drnlnni�r J❑ <br /> Grout material Iro Lo R..Cu.YAs. <br /> 13.NEAREST SOURCE6 OF P065IHLE CONTAMINATION <br /> �feel direction tyDe <br /> WeII disinfec�ed upon comple��on? Ve Nn❑ <br /> l4. PUMP <br /> Date ins�lei� ❑Nof inslalled ... <br /> ManufactureiS Name �y�, ����Q,� <br /> MOAeI Number HP�Volls� � <br /> Length of drop P�Pe � ft.cap.ci�y � e.p.m. <br /> Material of drop p�pe a+��� <br /> Tyve: tl's�Suhmersinlr 3�L.S.Turbine 5�lteclprocnling <br /> 3�lei 4�C'rnirifugal 6❑ <br /> Usensecondsheet,ifneeded �6.WATERWELLCONTRACTORSCERTIFICATION <br /> 15.HEMARKS,ELEVATION.SOURCE OF DATA,etc. <br /> This well was drilled urtder my jurisdiction and Ihis report is irue lo <br /> ihe best of my knowledge and belief. <br /> '�i��� ��.�.� �3 r��'�.�► <br /> Liceruee Buainexr Name Lfcmx Na <br /> naeRu l�?,`c�.�� i�—�t'' ��, �.�i��� ��r'1�31y �t <br /> �����k . <br /> Siened Date . <br /> Authorized Represeniative <br /> ��...L-i3ttJ.� ..7.��L� Date �"n�7'�U',� - <br /> Name of Driller 5/74:AM <br /> L��A` C°PY 4 0 3 7 6 4 7/7630M <br /> 7i76 30M <br /> HE-01205-0! 2B2 10M <br /> :� <br />