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JHN-15-2��9 11 : i2 AI•i LcUTHNER viELL INC 952 443 2�82 P. 01
<br /> WELI OR f30RINCi I.00ATIpN ����Ee�p�=�'•'•%,r�AI�IVT OF HEA47N Minn��ote Well end Eiorinp � '"�"
<br /> L ��ALING RECORD Sselinp No.
<br /> ca i �uam� �ND BO���i���::�.� M���aao�au��q�aw����Nc,
<br /> Minneeofa�t�rutaa, Chepfar f03! or W-e�rlea No,
<br /> ..+� (Lnti D4 Y na Ne.n�
<br /> 1' hip Nema Tbv�i�enlp Na R�nO�No, 6sod o. o�ln�lp,)I Dato 3ealetl /' � �ero W■II or BorM�onetrueted �
<br /> a w► I� .�8��0 '' �'U
<br /> aP$ Latltudu tlepreee_ minuteo_ eecende pa�W g��gN„np_,�_,It. Or�pin.�D�pih_„ T�h•
<br /> LOCATION: Lonqnuds+_ deqrese_._ m�nutu_� eeconde �ijWPl�(6) OTATIC WA1�R IEVCL
<br /> Numerlc�l 8truai Addreea or i�ire Oor:nd Clry ol Well o Loo4tlon L���^dU Aqultir ❑Multlaquller
<br /> (, � , � 1i+.�LLl�ORING L�Meaaured ❑Enlrtakd Dete Meaeured. _,_
<br /> (�W�iar-9upply Well ❑MoHit.W�II
<br /> Show ex�ot loo�tian o}well or borinp k;�toh m�p ol well or borinp �m.eoN Hol� (�,Other !� n.
<br /> In eactlon prld wlth^ff" locatlon,ehowlng prop•rty ,�1 _ ❑bNow [.]above land eurlene
<br /> N Ilnep,ioetl�,�ntl bulldinQe, cAf4INp TypC(8)
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<br /> ' tS�b�s�� ❑PIut10 ❑TIIB L�Ot�e�
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<br /> W I I I f� E � WELLH6AD COY�LlTION �,
<br /> --�---•••I-•--•i•• -•-I•• TMu� (�j'� I Oue�lda: ❑WNI Now� ❑Ai draee In�ld�: L�t�aoemen1011ea� '' '
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<br /> ; � �'tp / � �Pluee�AdeptarNnit ���urba ❑W�II Plt �
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<br /> �•• •••I•• ❑Burl�d I
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<br /> p omer �I
<br /> �1 MUa—�• ���OM01 � ""�
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<br /> PFID � OWNEp'8 NR MR4NV NRME CAOIWC!(o) '
<br /> • Dla ar De h 8ei in overelze hole7 Anrwl�r ap�w Inftlally prouted4
<br /> Prop+ny �m Inp Yd �fl d11N WeII loonllon addn�a InC �t�tl,qDqw., ,�In�lrom_� �� R ' ��01�;I�""��
<br /> ,,;.�.�<<�i cT t� �' ,�fL� �� . ❑Yo. n No r��� ' Ca N� , r�.���� ;I
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<br /> u' � In.from w I� rJ Yve ❑No rl ris ❑No (]Unknown
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<br /> �'` . !7�l� jl y 7 In,from io e. Q w� I_,J No
<br /> ❑YeB []No [�Unknown
<br /> WELL . '8 NAME/COM1�pAIdY NAME iCRGGN/OPEN NO�C
<br /> 8cre�n irom /� 6 to 13 r IL 0 m Hole from 10 _p �
<br /> WeA ownerl4.r�aAlnp sddrea.l!dlMsrcni ihan D�opvrry ownelx add�eee indkeletl ebov■ p
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<br /> ��arrtuc�rionre
<br /> , CJ Rode/orop Plpe U Ch�ak Valv�►�) [�Dobrle ❑FIII ❑No OWI�uaUon ,
<br /> 'f�pe oi Obaauctlons(Oeso�iha)
<br /> OLOLO�ICAL�d4TGpIA{, COLOp HMIDNO/OFi 'AOM TO ❑1`+1 ❑IVo G�wr�o I
<br /> �oBG�71oN Obetructlone remawtl7
<br /> II not kno�wn,Inelaete eeumet�d fo�m��lon Wp from no wall or borin , p���� _ -- �j�
<br /> TYP� "�V— ,�—
<br /> (,��mowd ❑Noi Preaent ❑OIN��
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<br /> � MlTFlBp USeD TO BEAL ANNULAR YW►C�YITW![N 2 CI►OIN00,OR CA8W0 AND YORi N04�:
<br /> ❑Nc annular 8pao�E�I�to ❑Annular 8pece Oroutetl wlth Thnml9 Plpv ❑Caelnp Perloraslon�Removrl
<br /> � In.Irom b _h.
<br /> . ❑P�Ao►�ted (;;7 Removed
<br /> _ In.Irom to I� (_�Perta�tad �Remaved
<br /> lype ol PeAorotor
<br /> U Omar
<br /> � ' o11DUTiNO MATLIIIAI(8� (On�a�rtrra■0�IO�.,ono b�p cl b�ntonllo a 60 Ie�.)
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<br /> aroutlnp MeNrl+l� Irom��_____r ►e� It, yarde E�ge
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<br /> trom---- lo It�. Y�rda bape
<br /> Iran to N.____,__,,,,, y�rdt bepa
<br /> OTMiR YY�LLB I►NO 60WINQB
<br /> pCil�A,RKB,eOURC!0�DATA,DI�riCULTIE9IN 9@AL�NO othor una�al�d�nd unuuad well or borinp on properry7 ❑Ytq �'No How meny7____.
<br /> L�ClNBCD OR REGIiT6NiD CDNTRAGTOR CRIITIFlCATION
<br /> , ,' ThIB W011 0�DO�I�Q Wu Nqlid In aaoord�naa wlth Minneeote Rulea,Chapter 4726,Th�Inlorm�tlon oontelned In th�e repoit
<br /> I�trW to l�beot of m nowledge.
<br /> �`` � l,v,�,Q ���� �Q�' �,
<br /> wo Buelneee Name Llolna�or Replerredan No,
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<br /> �� �� ��,����
<br /> rt/ed R�prNMfaNw 6lpnelure C'illfkd Avp Ma Daro �•�^�
<br /> LOCALCOPY M 1 �r��, l ��'^ �-�
<br /> ��io,�� Neme al Peroon 5�all�p Woll a Bariny _.__ ,��,,......_�
<br /> HE•01434•10 ICa 14o-od23
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