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STATE OF MINNESOTA DEPARTMENT OF HEALTH � <br /> 1 WATER WELL RECORD MlNNESOTA UNlQUE WELL N0. � � �;+;� �� � <br /> County Name �t���� � Minnesola Statutes l56A.01�.08 I�'Waler Sample t �.>' ..1 ,� <br /> � <br /> ,.., - Township Name i ownshi N�yumber Range Number Sectio{�t�o. Fraction 4.WELL DEPTH(mmpleted) Date o(Completion <br /> :).�"!�".��? �i.�l � .x::� or 13�. �i y w t`1/� r�"'�.�y�_.::� <br /> ____�' H, ri. <br /> �stance and Direction trom Road Intersection or reet Address and City of Well I.ocation 5.DRILLING METHOD <br /> ��C�yC'.: r��,...x;.��i--`� �:r������ : �� �; ����� 10 Cable tool 4O Reverse 7�Driven 1(IO Dug <br /> i�d. <br /> xact location of well in sectan grid with"X�." Sketch map of well loation. z�Hollow rod 50 Air SD Bored 1 t❑ <br /> � � � . dition Name , . 3�otary 6O Jetted 9O Power iauger <br /> --r- t -1 - �- 6.DRILLING FI,UID <br /> � � <br /> --+- -�- �- �- Block Number � � �. 7. USE <br /> yy i � I � E <br /> � T - . 1�Domestic 4O Monitoring SC]Heat Pump <br /> _1� _ I <br /> '�'�I ' ' � Lo[Number � 20lrrigation SO Public 9O Induslry <br /> � �fi mi. � <br /> 3O Test Well 6O Municipal IOO Commercial <br /> '-�- �- � —r' I 7O Air Conditioning 11❑ <br /> � 1 <br /> �—1 mile,� 8.CASING . HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME s 3.,�,�+�' .+�_1C1 � �s�. HEIGHT:Above/Below <br /> IO Black 4p Threaded <br /> �.:. �'C3�.�,.S4.�E:..�t,"r Surtace tt. <br /> .�`,':? � r �.- �-'l;I�. �y`.='�� 2O Galv. 5�Welded � <br /> Address �E.�'�-':i+�.:{.�j �.��.r «>�:..{F�1 3pP�astic � �y _ Drive Shce? Yes •J�o— <br /> ti �_i.t. �.�;.i.t.? <br /> in.to ft. Weight 16sJtL �n. to�t. <br /> 3. FORMATION LOG FROM TO in.to (t. Weight Ibs✓tt. �n. to�t. <br /> in.ro ft. Weight Ibs./ft. �n. to�t. <br /> �. . y ,-. .M.. .. <br /> c \'��:.L. .... .., ��'�. � ,, <br /> 9.SCREEN Or�open�o�?i: �� � <br /> Gom ([.to. ft. <br /> Make <br /> �i''�.� �.� ��C'i TYPe Dis. <br /> SIoVGauze �n�h FITTINGS: <br /> ��&�� J���� ��/ Set between ([.and it. <br /> 10. S]`qTIC WATER LE�EL �.,,.;�.,_�t�; <br /> tt.O below ❑above Da[e Measured <br /> land surtace <br /> 11.PUI1¢PdNG LEVEL(below ianc);sur(ace) --.; <br /> ,l: 'x t,u <br /> ft.a(ter hrs.pumping g.p.m. <br /> tt.atter hrs.pumping g.p.m. <br /> 12, .EAD WELL COMPLETION .�,].'�,� {����' <br /> 10 Pidess adapter.manufa�'urer mode� <br />� 20 Basement of(set 30 A[leas[12"above ground <br /> 4�Plastic casing protection <br />... . �3.WELLGROUTED? <br /> .� <br /> ❑Yes ❑No <br /> :�., !�i*.:.�;;3. ��c:.�.::i.�.I <br /> lO Neat Cement 20 Bentonite 3O <br /> Grout material from to tt.cu.yds. <br /> - 14. NEAREST SOURCES OF POSSBLE CONTAMINATION <br /> feet directior� type <br /> h <br /> Well disinfected upon completion? O Yes ❑No <br /> 15.PUMP <br /> �i.�'!C3 �Ji�L:a �� �t:�3. <br /> Date installed O Not installed <br /> Manufacturer's name <br /> Modei number HP Volts <br /> I.ength o(drop pipe ft. capacity g.p.m. <br /> MateriaJpf drop pipe <br /> 1� <br /> Type:lO Submersible 3O L.S.Turbine SO Reciprocating <br /> 2�Jel 4�Centrifugal 6O <br /> 16. EXISTING WELLS � <br /> Unused well on propeQFy? O Yes ❑No <br /> Use a setond sheet,iJ needed ppandoned � Permanent❑ Temporary O Not sealed <br /> 17.REMARKS.ELEVATION,SOURCE OF DATA,etc. <br /> • 18.WATER WELI.CONTRACTORS CERTIFICATION <br /> This well was drilled under my jurisdiction and this repor[is true[o the best of my <br /> knowledge and belie(. <br /> :�r:� �:�"�.�';�i�s �.d:., �l.i.►Yl� b..���„t :��� �.r�'� <br /> 1<��-�., !e� # �� �t,:�::t� �.��a�w�;,�,A <br /> Address <br /> :;"' � <br /> Signed DatP <br /> ,. W �y.a ����y�� Authorized Representative $,,,_�t�,�t�(� <br /> a� <br /> DatP <br /> Name of Driller <br /> LOGAL COPY 4 5 81�6 5/"� <br /> �ns aa�,� � <br /> �i�e� <br /> HE-0120502(Rev.10/85) 2/82 10M � <br />