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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CounryName WELL RECORD � ��� � � <br /> ��X �e/iCl� i n Minnesota Statutes Chapter f 031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion <br /> Qrnno II8N 23W 21 NE,,,NK,,.SW ,,, 267 n 21/6/92 <br /> Numerical Street Address or Fire Number and City of Well Loration DRILLING METHOD <br /> 936 Cox farm Road Long Lake, f�l 55356 �� CableTool �- o���e� � 0�9 <br /> I Auger � Rotary C Jetted <br /> Show exact locatian of well in section gnd with"X". Sketch map of well location. <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> --�- �- -j -i- water <br /> i i � USE <br /> '-+- --- �- �- ffi Domestic � Monitoring f�; Heating/Cooling <br /> � ' 1 <br /> W � � ET C Irrigation I; Public _: Industry/Commercial <br /> -� -1- -;- �- I C Test Well Dewatering f7 <br /> � f-mi. <br /> � , CASING Drive Shoe? I Yes � No HOLE DIAM. <br /> i <br /> --i- �� —�� [1 Steel ' Threaded - Welded <br /> � � Plastic � glue <br /> �m;le� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME in.to <br /> j 52 n. ibs.m. ���.ro1�Z n. <br /> Ja�es F. Nanson ��._� tt. Ibs./ft. in.to_tt. <br /> Mailing address if different than property address indicated above. in.to fl. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make �C� from ft.to ft. <br /> Type Diam. <br /> SIoUGauze c S 0� Length <br /> Set belween V ft.and lfi7 ft. FITTINGS: <br /> HARDNESS OF STATIC WATER LEVEL <br /> FORMATION LOG COLOR FORMATION FROM TO l��j ft. �� below � above land surtace Date measured 1� 6 �2 <br /> PUMPING LEVEL(below land surface) C <br /> Tapsoi 1 bl ack 0 4 n. afte� hrs.pumping J� a!a i r q.p.m. <br /> WELL HEAD COMPLETION <br /> Cl ay ro�� 4, 1 C� �Pitless adapter manufacturer ���5 Model � <br /> � Casing Protection <br /> 4�a f+a 15 32 GROUTING INFORMATION <br /> Well grouted? � Yes ❑ No <br /> Grout Material � Neat cement ;i Benronite <br /> Cla & ravel ra 32 86 ,�om 0 to 3� n. � YdS. L bags <br /> from to ft. ❑ yds. ❑ bags <br /> SE��"� � �"�ye� �t� �� 92 from to ft. '� yds. ❑ bags <br /> NEAREST SOURCE OF POSSIBLE CONTAMINATION <br /> L�a & ravel ra (�,�1 t �2 !Q� feet direction type <br /> Well disinfected upon completion? �Yes � No <br /> b�C� Q r{3v�� rown �ul i PUMP <br /> C7 Not installed Date installed <br /> c.,,.jp * Manufadurer'sname Go�tlds <br /> JCF#U Ot ravel 1 aC� �'Q� Model number HP___1__�,�`�Volts���'� <br /> Length of drop pipe 3 46 ft. Capacity I$ g.p.m. <br /> Boul der 1 ack wh i e �2 2 Pressure Tank Capaciry �i <br /> Type: � Submersible L I L.S.Turbine I' Reciprocating - Jet � <br /> ti�a � sand rOUVI� RIU� � �2� � AgqNDONEDWELLS <br /> e,, ,�i p� Not in use and not sealed well on property? C 1 Yes � No <br /> JO��i R ravei 1 ti � WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdication 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�needed Stevens Wel t Qri 11 i ng Ca.,I nc. 27194 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Liaensee Business Na , Lic.orReg.No. <br /> i�r� � 11/9/92 <br /> Authonzed Representative Siganture Date <br /> �ae Stevens II/9192 <br /> Name o/Driller Date � <br /> LOCAL COPY � � Q � � � HE-01205-03(Rev.9/91) <br />