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;WL )CATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br />County..ameHamwin WELL RECORD 536272 <br />Minnesota Statutes Chapter 1031 <br />Township Name Township No Range No Section No Frad*. WELL DEPTH (completed) Date Work Completed <br />117 23 66 41-0073 47 I 7I-' <br />1 <br />Numencal SIr40111 Address and City of Well Location or Fire Number DRILLING METHOD <br />030 EZ=n Street Orcm, Mtn. Cabe Tool ❑ Driven Dug <br />Auger RoWy Jetted <br />Show exact location of well in section grid wrth'X' Sketch map of well localan <br />Showing property Imes. <br />M roads and buildings DRILLING FLUID <br />os=Ii <br />EEO <br />WEE® <br />I_ I mrk <br />PROPERTY OWNER'S NAME <br />Matting address 0 different than property address mOratad stove <br />``22075 Hra�.: wtts Fbad <br />►7lsU / Nn. 55 _�31 <br />GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM <br />MATERIAL <br />ClayS C <br />Sand S 1101 <br />Use a second <br />REMARKS. ELEVATPOW15bURIP WbAtA, etc <br />SEP 21 1994 <br />.USE DomesticMtxtd .: HeabngiCoohng <br />°`"n IndustryrCommercral <br />. Irrigation ❑ Public Remedial <br />Test Well rl Dewalenng <br />` L CASING Drive Shoe? " Yes NO HOLE DIAM <br />Steel Threaded Welded <br />r 3LPlastK <br />CASING DIAMETER WEIGHT <br />4 at. to 128 ". —Want. _7_�8ro 30It <br />ig Homes Lx <br />_— n. to _.. R .. - -- baA. on. to " <br />SCREEta:_a__-_-_ - _ OPEN HOLE <br />Make - __ from _ ft to. -_ _ -_-- __-" <br />Type StdiY11(�S St mi Dam <br />slovGa _ _ 1 L 1 U Length <br />Set between _ 1 �_)a 1 ". Ytd If FITTINGS: 4 a <br />STATIC WAT//Si�LEVEL <br />TO _ If ,a below ❑ above land surface Date measured '1- <br />PUMPING LEVEL (below land surface) <br />h aher - -- - hrs pumping - - - - g p m. <br />WELL HEAD COMPLETION <br />13l ' qt PRless adapter manufacturer _ _ — Model -- _ <br />Casing Protection_---_----_---- ------_-__ ? 12in.above grade <br />GROUTING INFORMATION <br />Well grouted? X: Yes : No <br />Grout Material ' : Neal cement ,ZBanlmft <br />from— _ (�-- to —3 _ 3 __-- ❑ yasXJ bags <br />from to__ — ". —_-_-- ;; yda '7 bags <br />from to _._ it '1 yds ".; begs <br />NEAREST KNOWN SOURCE OF CONTAMIN TIO42 y <br />7�'' - feet wS - direction 5 y►ra type <br />Well disinfected upon completion? X Yes No <br />PUMP <br />Not installed Dale installed <br />Manufacturers name <br />Model number - HP Voft -- <br />Length of drop pipe _. - n Capacty <br />Pressure Tank Capacity T_ _ <br />Type Submersible rJ L S Turbine Reciprocating Jet <br />ABANDONED WELLS <br />Does property nave any not in use and not sealed well(sl' Yes X No <br />WELL CONTRACTOR CERTIFICATION <br />This well was drilled under my supennsion and in accordance wdh Minnesota Rules Chapter 4725 <br />The �inf�ormation contained inntthis <br />srreport <br />t's true 10 the blest Of M know)adyp�ey. _ _ <br />N�.Ia� 57GD" alf�We/ irR.IIaLxIW 66. � 1a C. L / 1 I L <br />Lrr ensee Brusress Name Lie a Ray. No <br />5-31-94 <br />Auenorrzed Rep+esen! ve SgnaNre iD4s <br />F.P, hdMahm 5-31-94 <br />LOCAL COPY 1513 6 ' _" 7 21 HE-0 1205-04 (Rev. 5" <br />