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STATE OP MINNESOTA GEPARTMENT OF HEALTH
<br /> 1. OCATION F WELL �� ,L//A'NESOTA UN/QUE WELL NO. A 7 7 4 Q 9
<br /> County Name _ WATER INELL RECORD
<br /> /]�,� ,�, Minnesala Slnlules 156A.01-.08 fos Wa[rs Sample �#
<br /> �..+�"�"'.'.. �f.I�'�-�,
<br /> Township Na e � Township Number Range Number Sec[ion No. Fraclion 4.WELI,DEPTH(completedl Date ot Completion
<br /> E
<br /> �� ���-�- ! / 7 � �� f p ��.,,,5� �, �..�''� /� f� S , ?� �
<br /> Numerical Stree[Address and City of Well Location or Distance from Road Intersection. 5. DRILLING METHOD
<br /> ���� �-- ❑Cable'lool ❑Reverse ❑Driven ❑Dug {
<br /> ! ,-... ;�- ..�} ...._,
<br /> Show exact oca[ion ot well in section grid wi[ ' . � ,Sketch map of well location. ❑HollowKod ❑Air ❑Bored ❑
<br /> N f j;7
<br /> � � i i Addition Name i%��� �-^�-a.,..,,,,,.., �Rotary ❑Jened ❑Power Auger
<br /> --r--�- -1 -1- � � � 6.DRILLWGFLUID
<br /> �"
<br /> � ' i 1
<br /> ._y_ ___ _ �_ Block Number �,
<br /> yy i ;�! i � E � � 7. USE
<br /> i
<br /> _1_ ___ _,_ __ � �i Domestic ❑Monitonng ❑Heat Pump
<br /> I � � I Lot Number O Irrigation �❑Public ❑Industry
<br /> f-mi. �,.i
<br /> � i i � - ❑Test Well {]Municipal O Commercial
<br /> --�- �- - -r- „g'� � ❑AirConditioning ❑
<br /> � , ' � � fi ... �,.�-
<br /> � , L J��-��"°"°�"� g,CASING HOLE DIAM. �
<br /> �'—1 milE'—� "_" - i
<br /> 2.PROPERTY OWNER'�AM� Mailing Address if different than propeRy address ❑g�ack HEIGHT:Above/Below �
<br /> ❑Threaded
<br /> � iodicated above. Surtace h.
<br /> ❑Galv. ❑Welded C
<br /> Drive Shce? Yes—No�
<br /> � �Plas[ic O �-+;�
<br /> � � -� . .�_.�in.to /�!` tt. Weight�IbsJft. .�' n. to,� v rt.
<br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight IbsJ(t. �in. to«1t.
<br /> FORMAI'ION
<br /> in.to fL Weight IbsJtt. _�n. to_�t. -
<br /> .,,�� J� �',..�`..r, r� ;, � � � 9.SCREEN Or�open hole
<br /> ._ ' '�� (rom (t.[o. ([.
<br /> Make �
<br /> n r� ,/ '[ n } -.�-.
<br /> � -(..�G� ��'i-R^9� Y� � { TYPe �,�j�._. .�1�.� �.�1 t{� Diam. �,
<br /> !,.�
<br /> SIoVGauze f �- Length�
<br /> a F TINGS:
<br /> ; �� � - L j� �'i-.-� �1� �� Set brtween�ft.and���ft.
<br /> �qp-� I0. STATIC/WATER LEVEL
<br /> �;�,.�,�,_:;� ti n � ��s �`� / v �f r� L'/ � ft.gbeluw ❑abo�•e Date Measured � � -f� �.,�
<br /> lan surtace
<br /> R�� 1l. PUMPING LEVEL(below land sur(ace)
<br /> 1. p /
<br /> 'f',�.^''';.:...3,-,p„_!� :,.e,,Yv"..! �8....�'' f s ! �� z fL atter�hrs.pumping , d B.p.m. �
<br /> ft.after hrs.pumping g.p.m. �
<br /> 12.HEAD WELL COMPLE"1'ION }�-
<br /> RPitless adapter manu(acturer ��`�'��-•'��ti"� Model_�._�S�_�-_ -
<br /> 'O Basement,o((set ❑At least 1'L"abuve ground
<br /> ❑Plastic casing protection
<br /> 13. WELLGROUTED? ❑Yes ❑No
<br /> � �Neat Cement ❑Bentonite ❑
<br /> Grout material trom ��,• to�_—ft.cu.yds. _
<br /> �;.
<br /> t ;
<br /> la. Nt:AREST SOURCES OF POSSBLE CONTAMWATION� . ,P r
<br /> �V �'..._i _ . ���l(eet �1--4aL direction 3`����'-�" "�'ti' .v.� �YPe
<br /> Well disintected upon completion? �1'es O Nu °� ,�li:rz��,�
<br /> lu. NUMP
<br /> � .��A Uate installed �� � � �� O Nol installed
<br /> �. s
<br /> ����� � Manu(acturer's name ' �'�-"4i'-�7'�-
<br /> Madel number � � �" � HP ��1 Vol[sv i��
<br /> Ixngth of drop pipe �u (l. Capacity � � g.p.m.
<br /> Material of drop pipe ��"'�"
<br /> Type: �Submersible ❑L.S.Turbine O Reciprocating
<br /> ❑Jet ❑Cen[rifugal �O -
<br /> 16. ABANDONED WELIS
<br /> Unused well on property? �,Yes ❑No
<br /> (:se a srrond sheef,ij needed Sealed Permanent ❑ Temporary ❑ Yot sealed
<br /> 17. REMARKS.ELEVATION,SOIIIZCE OF DA7'A,etc.
<br /> � I8.WATER WELL CONTRACTOR CENTIFICATION
<br /> This well was drilled under my jurisdiction and this report is true to the hest of my
<br /> � knowledge and belie(.
<br /> /i' .r�`.S r`., ,�-U�.-'�.-C,�� i 4 > 7.� 7 L
<br /> � Licensee Business Name ` . Li�ens�e rN�a. /
<br /> Address �/t�� „�Q �•�- y�.�..9' Y°'v�r/�, t-�, , .t-L-,.fy� f.
<br /> �� {�`'
<br /> Signed�r-�- `�r;-�'LR..�Z{ Date�� /f � �j
<br /> �^
<br /> Au(horized f2epresentafiue
<br /> ��, ,�.. .�'� .-�;,,, ;_ � Uate ' �'�
<br /> �� Nn me of (Ier
<br /> 5/74 30M
<br /> � � � �o � 7/76 30M �
<br /> LOCAL COPY HE-01205-03(Rev.9/88) 2/8230M
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