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STATE OF M[NNESOTA DEPAR7'MENT OF HEALTH �� <br /> l.LOCATION F WELL � ,Nl.NNESOTA UA7QUE WELL NO. ������ <br /> Counry Name WATER WEtL RECORD <br /> r` � �Ninaeso[a S[afufes 156A.07�.08 fo>Water Sample <br /> --�� ,.,ti "bi <br /> Township Nam � Township Number Hange Number Section No. Fraclion 4. WELL DEPTH Icomplettdi Date o(Completion <br /> ._ N E � - � �.�� <br /> v� i �i� <br /> t�'� �:,: �i/�✓1> ! � s 2 w '�� �" _ �r� _ n. . �'/ <br /> Numerical Street Address and City of Well Location or Distance from Road Intersection. 5. DRILLING METHOD <br /> � � � �,. f. ❑Cable"lail ❑Reverse ❑Uriven ❑Dug <br /> i ( t / ^ .f ..'!'.� •'t.,..., <br /> � $how exacl Iceation ot wel'in sec� grid with"X." Sketch map o(well locatioa O Holluw Kud ❑Air �Hored ❑ <br />�; N <br /> � � i Addition Name +...� `[/�� otary ❑Jetted ❑Power Auqer <br /> --r-'y- -� -1- '�� 1�,,.� 6. URILLING F'I.UfD <br /> � � � � Block Number � / <br /> w '-+- -7- - �- � j 7. USE � <br /> � I � <br /> � <br /> _1_ _3_ _,_ __ T � � �1 j J f$Domesuc ❑Momtonng ❑Heat Pump <br /> I , i � I Lot Number t ,„ � p ❑Irngation ❑Publk ❑Industry <br /> f�mi. t ( <br /> a�� _�__�,( �"I'est Well {]Municipal ❑Commercial <br /> --�- -�- � -r- I `4---�+^*"'"'""'" t ❑AirConditioning ❑ <br /> ' � � � j <br /> �1 milr� 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if differen[than property address ���a�k HEIGHT:Above/Below <br /> ❑7'hreaded <br /> =-r-� indicated above. Surtace ft. <br /> �;;''`'�r;'� �,r . ❑Galv. ❑Welded <br /> - � Drive Shce? Yes_ No— <br /> `,_ ,,; f�Plastic ❑ <br /> �� r � y "�" <br /> '' t' ..�"'��i"� �in.to ��T tt. Weigh[�Jef�IbsJfL �in. to-�t. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight IbsJft. y�n. t�t. <br /> FORMATION <br /> in.to fL Weight Ibs./ft. —�n. to�t. <br /> �'� ��� -� � . <br /> ,�,,.p,,,�..�„ :'t:t.,. - l` � 9.SCREEN Or open hole <br /> ' -'� Make �� ���� - r-»-� from ft.to. ft. <br /> �'�" � ' �-. � r` -+ � � � ,t <br /> ��el'' . '�:r±. �.'ti..r� . ✓ l e�� Type_�� f�_yd� � i�� Diam. -+ <br /> ' . SbVGauze f�,�I I.ength� <br /> � FI INGS: <br /> ,,.�'_.f : -_.�-. . , ,�A"�� �" �� Set between�tt.and�ft. � <br /> 10. STATIC WATEK LEVEL {. <br /> �y '-� ft.;�below ❑aboce Dale Measund A� - "�� ('�/ <br /> land surtace <br /> 11. PUMPING LEVEL(below land sur(ace) � <br /> � r/tt.a(ter—.._.�hrs.pumping -1 � g.p.m. <br /> (t.after hrs.pumping g.p.m. <br /> 1'L. HEAU WF,LL COMPLE7'ION �^ <br /> {�itlessadaptermanu(acturer ��,�--I�'^^----^�^' Medel j� ' �t <br /> '.O Basement,o((set O At least 1'L"above ground � <br /> ❑Plastic casing prolection <br /> 1"3. WELL GROUTED? G�+Yes ❑No <br /> � �Neat Cement ❑Benronite ❑ <br /> -..nc <br /> � Grout material from{..�.a. to—r4�—f[.cu.yds. _ <br /> i- <br /> ��� .�� ^ <br /> , ` <br /> 14. NF.AREST SOL'RCES OF POSSIBLE CONTAMINATION <br /> _ � (�(eet � direc[ion ��� � �-�„ [ype <br /> - � Well disinfected upon completion? ,C�'es ❑No ,1�„�� <br /> � .�91 i;. i��m�v ` <br /> � Date installed (� ` �� � � ❑Not installed <br /> - " � Manufacturer's name f } <br /> Model num6er ^� 7>��..` HP�Volt4' �� <br /> Length o(drop pipr �^"L ft. C apacily � r` g.p.m. <br /> Material o(drop pipe �� -�t-..�.- <br /> Type: �Submersible O L.S.Turbine ❑Reciprocating <br /> ❑Jei ❑Centrifugal O — <br /> I6. ABANDONED WEL(S <br /> Unused well on property? �Yes ❑No <br /> Use a serond shee(.�/needed � Sealed Permanent ❑ Temporary ❑ Not scaled <br /> l7. REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> � 1H. WATF,R WELL CONTRACTOR CEKTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best o(my <br /> knowledge and belief. � <br /> ` � .%�. t..,,..��..�.�r '�,-f" � ? .�� � <br /> ��`� `� <br /> Licensee Basiness Name : Lirense Na. / <br /> Address �!� �fJ f,.�' .��� r�. f �G'l�,e��f �%�l-'>,�/.-�_. <br /> f - ."L"`. �' i f` <br /> Signed f _ �.-.. Date �� � �f <br /> Authon�ed Kepmsen[aflue <br /> .�_v:._ ^ .� .. �'r �. <br /> -� �-"-x-� Date�� <br /> � NarneofDriller <br /> 5/74 30M <br /> � 7/76 30M <br /> l_QCAL COPY ��7 � � � xE-ouos-os�xe�.9iss� v'sz3oM <br />