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� WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO.
<br /> CountyName . WELL RECORD 5 613 7 2
<br /> �"-�''�`"� -' Minnesofa Sfatutes Chapter f031
<br /> Township Name Township No. Range No. Section.No. Fraction WELL DEPTH(completed) Date Work Completed
<br /> � ':t:;�c ; 1 t . . '� f, , _ " _
<br /> �a v. �i.
<br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
<br /> • , , , :_ ❑ Cable Tool ❑ Driven ❑ Dug
<br /> ,,.,.. ;.:_LC � L'1"��t_'.
<br /> `" � ' -- i �`-^'` ' - ❑ Auger ❑ Rotary ❑ Jetted
<br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑
<br /> ShoW property lines,
<br /> N � �)'� ads and buildings. DRILLING FLUID
<br /> I i � �
<br /> __r__y_ _1 _1' � Jrt,.
<br /> U•
<br /> � � � i ,USE ❑ Heating/Cooling
<br /> ,_a_ _:_ �_ �_ 4,Domestic ❑ Monitoring
<br /> W ' i � E ���ti O lrrigation ❑ Public ❑ Industry/Commercial
<br /> ' T � I .�;�i.� ❑ Test Well ❑ Dewatering O Remedial
<br /> _1_ _i_ _'_ _' I
<br /> I , i �
<br />+ �'�'"'� �� � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
<br /> � '
<br /> '-�- �' - -�' 1 � O Steel ❑ Threaded ❑ Welded
<br /> - -� Plastic ❑
<br /> ~—1 milr—� - .
<br /> CASING DIAMETER WEIGHT
<br /> PROPERTYOWNER'SNAME �� in.to i`-�ih �?'�.-_ r �bs� iri.to `tt.
<br /> "_ 'i r.. , .,-• —
<br /> � -: in.to R. Ibs./ft. �_�ytp��ry.
<br /> Mailing address if diRerent than property address indicated above. in.to ft. Ibs./ft. j�,to tt,
<br /> ,t:, 1 i-;r SCREEN OPEN HOLE
<br /> ,, , ..
<br /> � -
<br /> � Make ��....=..1.1 1�- ;..?=.'i from ft.to ft.
<br /> .. .i.' �. ..�� . . . .. � ... TYPe •.�.,_,P� `�; ���, Diam.
<br /> SIOUGauze���1-},:�'h�_����� Length �
<br /> Set between !::� 1 � ft.and I".�'�:� ft. FITTINGS:
<br /> STATIC WATER IEVEL
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO R. [3;below ❑ above�and suriace Date measured t
<br /> MATERIAL '
<br /> PUMPING LEVEL(below land surface)
<br /> �.lc:a j . � f � ft. after hrs.pumping g.p.m.
<br /> WELL HEAD COMPLETION
<br /> ;,�;;,-�.21(j , �-��i-' ���-;�. C3�,.,Pitless adapter manutacturer s�'.;��-;* ����- Model
<br /> ❑ Casing Protection p 12 in.above grade
<br /> ��.�-���'Y� . �_;'_ S E:.�..� GROUTING INFORMATION
<br /> Well grouted? C3,Yes ❑ No
<br /> r.,t� �� : s ��,: Grout Material ❑ Neat cement Q Bentonite
<br /> from �to _ ' ft. _ :-: ❑ yds. 0��,bags
<br /> from to ft. ❑ yds. � bags
<br /> from to ft. ❑ yds. ❑ bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> ^- <<,��-
<br /> ��//,.�_feet "�F�� direction '" t ' � type
<br /> Well disinfected upon completion? ❑Yes ❑ No
<br /> PUMP
<br /> ❑ Not installed Date installed (`^ -'���`";�� �
<br /> Manufacturer's name �� � �"k
<br /> Model number $°�c�;'�_� HP 1; Volts , ,
<br /> Length of drop pipe �,��� fl. Capacity _1{' m.
<br /> 9P
<br /> Pressure Tank Capaciry {.",�'='�..i�'� - '"'r,-t
<br /> Type: O Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet O
<br /> ABANDONED WELLS
<br /> Does property have any not in use and not sealed well(s)? ❑ Yes ❑'No
<br /> WELL CONTRACTOR CERTIFICATION
<br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
<br /> The information contained in this report is true to the best of my knowledge.
<br /> Use a second sheet,ilneeded ?A +t ��f��f,;' t i:.,�: i t��.y.�i.�.,r.!l.j '''� � t i �
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name Lic.or Reg.No.
<br /> � ���._._. " :
<br /> .- .
<br /> �-/i��Cir� ti c..�...c...... ._
<br /> � J Authorized Represenfative Signature � ' Date r
<br /> _ ._ . , Cl.. . .:i'_ < -�'` Z.
<br /> Name of Dri/ler Date
<br /> LOCAL COPY 5 613 7 2 HE-01205-04(Rev.5/92)
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