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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br />ABAXDO0_wD WELL RECORD <br />I.•LaAtwo—OF WELL <br />MINNESOTA UNIQUE WEL! NO. <br />:lease blank it not known! <br />Councr <br />Townshi <br />Townsr'D Iku111110rlkingo <br />•N <br />Number <br />E <br />Section No. <br />Frattsell a. <br />WELL OE -TM � Date sealed <br />]0 <br />4 4 of <br />Numerical Street Address and City of Yell LOu on Or Oi stance frpm goad 5. <br />TRILLING METHOD Ilf known) <br />Inc non <br />1vT <br />i <br />�MI'I! i <br />JIVV (f� s <br />10 Cable toot 40 Reverse 70 Dri ,fn 100 Dug <br />2[J Notlw Rod S[]Air �6ored tl(.j jit <br />Shw *.act location Or Wa11 <br />10 Rotary 60 Jetted 90 Dower Auger <br />(in section grid with "X'i <br />Sketch map of Well locution 6, <br />Oa 7;iUCTIOnS <br />_ L _ <br />_ <br />_ <br />.' <br />0 <br />Wall •bstructtd 0 Yes No <br />Obs t rbc ti ant re=vtd 0 IN []No If obstructions Cannot be <br />a <br />COn tact MOM <br />' <br />Wayed. <br />Lore Waling, <br />j j <br />USE <br />DOMft iC 40 Mom ltOrl ng go Neat MOOD <br />Irrigation So Publ1C 90 Industry <br />Test Wall 60 whlc Ipal IC10 Corrc I a I <br />1 w1. <br />70Air Conditioning 110 i <br />2. PROPEATI OWNER'S NAME <br />Wliing Address +• different than <br />e. <br />f <br />NG(S) <br />property addnff +ndiuted ADOyt <br />Black 40 T11readed 70 <br />' <br />Gals. S❑ welded <br />30 Plastic 60 Stainless Steel <br />HARDNESS OF <br />O. FORMATION LOG COLOR FORM TiOM FROM <br />If not known, indicate forgtion log from nw well or nearby well. <br />16. REMARKS, ELEVATION. SOURCE OF DATA . CASINGS REMOVED, CASINGS <br />FFtCIAL AWDONED WELL RECORD Kay Wa used for Property TrAntfer: <br />ZJUICWA&rs IIEJ NITn 04= <br />r0 In. to ft. <br />In, to ft. <br />9. SCREEN <br />0 SC roomed Wall from _ ft. to ft. <br />(fI known) <br />. 0 Open Hole from ft. to ft. <br />110. STA(IC WATER LEVEL <br />f It. 0 below abort <br />land fu rlsce Data Measured <br />III. JELLMEAD COMPLETION <br />!' 10 Pitlest Adapter Q Found Furled <br />I esit mnt offset 50 <br />yell Pit <br />I12. GROUTiN6 INFORMATION I <br />IVNfat Ctrnt 70MY, to" Ito I <br />G1/out eaterlal r,n [ j t0� Cu. ydR� <br />13. ejAREST SOURCES OF COVIAMi NATION <br />feet _jjRWZ_ directloM r` -r <br />cell dlsinfocted before__ tooling? res Ts-� <br />;a. DUMP Aetp red �t Prf t <br />,Yoe INISubse Ibit U L.S. Turbine Rec,orocatinq <br />f <br />70 Jet 40 Centrifugal 60 <br />! <br />�15. EXISTING WELLS (Please sketch locations Of atandonen and ! <br />attire Wa11s In remerkt sect 0 0, 0n flack.) ' <br />Othfr muted Wa11(a) On pro ptrtyT 0 Yes No <br />Abandoned: I] Permanent 0 Temporary No felled j <br />17. WATER WELL CONTRACTORS CERTIFICATION --�� <br />This weft was Pealed under ey jurisdiction and this report <br />11 l ue to the belt Of *y thowledge And eel'ef. <br />_ ICfnfet Bufiness Name Llcentf No. <br />e � <br />Add,#%% <br />i - l <br />Data <br />Now of Driller <br />