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STATE OF MINNESOTA MZN9ESOTA UNZ@UE WELL N0. <br /> �PaRTr£rrroFH�n� WATER WELL RECORD 127355 I <br /> for W¢ter Srmrple <br /> l. LOCATION OF l7ELL Minnesota St¢tutes L56A.OL-.OH <br /> _"'_____�_—__ <br /> � Co�mty Name Fraction Section Number Tovnship N�her Renge H�ber 3. �OPERTY ONNER'S NAFff - '--�-� ' <br /> � � � � ����� .... �. <br /> N. or 5. E. or N. Address � t� �"`�� <br /> Distence and Mrection f?om Road Intexsections or Streec Address and City of We11 Locacion � ��as�,q. �� �Q:i. <br /> ��� �i <br /> ........__.'_-"'...._.._._...__......__...,__..__......_._ <br /> Shov exact location of vell in section grld with 'X.' Sketch map of well location. , }/gLL DEP77[ completed) Date of Completion <br /> N <br /> - L -,- ! �- � n. a�.'•�a�� <br /> W _ ± �- y E 5 1Q Cable Lool 4❑Reverse 7❑Driven LOQ Dug <br /> +- <br /> ' i , '�Hollw rod 5❑Air �Bored ll� <br /> , �� � ' , '�mi. 7�Rotary b❑Jetted 9�Power Auger <br /> -� � :�.'___ <br /> � ___ ... -'---- - -� -- 6. use <br /> + I� __. <br /> S 1�Domestic �Public Supply 7U Industry <br /> ~—1^^�� Z❑Irrigation �Air Conditioning 8❑Covvnercisl <br /> HARDNE55 OF <br /> 2. FORMATION IAG COLOR FORMATION �OM TO 3❑Test Nell 6❑ <br /> �� � �� � � 7. CASING HEIGHT: Above <br /> DIAM. <br /> Threaded�1 Welded Q 3I Surface ft. <br /> Slack �� Gelv. �4I <br /> � & � � �in. to � ft, depth ( Weight �*E**►"�' lbs./ft. <br /> in. to ft. depth I <br /> in. to ft. depth Drive Shoe? Yea No <br /> . SCAEEN Or open hole <br /> Meke ��wey�i from ft. to ft. <br /> �� '4'Pe S r-i�-..13lJ��Dia. �� <br /> t� Slot/Gauz---y;e�� Length � . <br /> �j�� FITTINGS: <br /> Set betveen�F61 fc. and� [c. <br /> f[. and Et. <br /> _ f[. and f[. <br /> � <br /> 9. STATIC WATF.R LEVEL <br /> � � ft.�lov �above Date Meesured���l.� (. <br /> � land surface <br /> 10. PUN�+'�IttG.LEVEL belw land surface <br /> �"'� ft. aTter � hrs. pumping � g.P.m. <br /> ft. after hrs. pumping g.p.m. <br /> 11. WELL HF.AD COt�LETIOH <br /> i�Pitleas adapter Z❑Sasement offset �❑At least 12" above <br /> qrade <br /> 12. 'dell gmuted? <br />� �Yes �No Cu. Yds. <br /> 1❑Neat cement 2❑Bentonite 3�� ��_. �� " <br />�� Denth: from ft. Lo ft. <br /> Ifrom ft. to ft. <br /> li 13. Nearest source of possible contaminatian � <br />��� _feet di recti on type <br /> ._ Well disinfected upon completion? Yes� No� <br /> 1 . PUN� <br /> Date inetelled ����� <br /> �Not installed <br /> _ Menufacturer's Neme � �� <br /> hbdel t7umDer kIP �7 �� Volts f,�._ <br /> Length of drop pipe �i{yF ft, capaclty�.� g.p.m. <br /> Materisl of drop pipe �# ���♦ <br /> Type: 1�Submersible 3O L.S. 'Purbine SQ Reciproca[ing <br /> Z❑Jet 4❑Centrifugal 6� <br /> 16. WATER WELL CONTRACfOR'S CERTIFICATION <br /> This vell was drilled under qv ,Jurisdiction and this report is Lrue to <br /> the best of vd knwledge and belief. <br /> �ae a aecond aheet i needed. � � �'�� �'t�� �a �„�� <br /> 15• ��K�, ELEVATION, SOORCc OF DATA, etc. Licensee Busin¢sa Name Lticense No. <br /> Address_IE��+'_�. � � ���� � !�F-_���� <br /> _> -,� .,y„>. - ,, <br /> Sip3�e .���'":.:...�� t'�:'Y+�r.x'�"'"����Date - <br /> Authorized Repre�entative <br /> ` LOCAL COPY �� �� � <br /> Neme of Driller 7/74 30M <br />