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STATM.()h MINNI:S()TA UF�.1'AN7MF;NT OI�IIF:ALTN <br /> I. l.(1('ATI()N UI-WF�LL M/NNFSOTA UNlQUF WEl.L NO. <br /> c�����rN.�,< WATERWELLRECORO 40376� <br /> � ro,wure.sumplr <br /> Minneso(o StaNte+/ShA.l1l�.flN <br /> T��wns��p Nam< Tnwnship Numher Han�c Numher yccli��n N�. I�ra�tli�n l. YROYlRTY OWNF:R5 NAMk: <br /> N � E �. Y. / � . <br /> �� Sr W '�� <br /> . I)istani�and I�wec�iun frum HouJ Inlrrxcti��n�ur 5�rce�AJJress anJ('��Y of W�II I.oc��ion Address '2� Py��w}�.� <br /> 7�►b�Ri.#ili� <br /> t� � �; �'�`�! <br /> 5n�iw ea.�t li�ca�iun o(well in ucllun priJ wilh"X." Ske1cA map o!w<II loc��iun. 4. 'LL DEPTH(completed) Dale of Compl<tion <br /> � AJJ�I���n Name ����, <br /> _ �_ _ N . _ _�� n. � <br /> i - i - - I-- 5'iOc.niri����i oOk��r... i�n,�.�� io0o�` <br /> N -� - -'- -+-I - G Nl�ick Numhe' Z�HnllnwruJ S�AIr B�Bored I I❑ <br /> ' - - '--_� �ML. )O N"��rY 6Oleifed 9❑Ynwrr Auger <br /> ' � ' � � Lo�Num�er 6. USE <br /> 'i_ ' __'' __ _'_•'_ <br /> �Ih�meslic a❑YuAlic SuDD�Y 7�Indus�ry <br /> � <br /> F--1�II.tI� Z�Irrigalinn 5❑Municipal B�C'nmmer<ial <br /> 3. FORMATION LO(: ('OLON MANI)Nh:5501� F�µOM TO <br /> !()NMATIUN J❑Te�t Well 60Air('i�nCilionin� 9❑ <br /> 7. CASING HF:IGHT: Abov</Below HOLE DIAM <br /> � �� l�,.�. � 1❑Black 4�Threadrd <br /> �.i' <br /> 2❑Galv. 5❑WelAed Sur(ace (t. <br /> Y�� �2� � '}� �PI85tiC y❑ Drive Shoe? Ve�_ No� <br /> 14F�` ;� �{��Q <br /> � �n.to �� ft. Weighf ��l�� Ibf.(ft. In.}di7.j—ft. <br /> �:� �� �y �Sy in.to ft. Weitht IAs./ft. —n.to_ft. <br /> �n.to h. WeiRht Ibs./!1. _In.�o_ft. <br /> ����Y�p w1 id�R �� �j� B.SCRElN r open ole <br /> .w.,1��V 1Y.iRi� 7 � <br /> Make hom !t.to tl. <br /> �3r�a �p �a�r �1 7� TYo� � o�.. � <br /> SI�tfGauz< �� Lengfh � <br /> �+J�'g� i�ITTINGS: <br /> ♦ _� a � wA ��_"' Selbelween � (�.an0 .j�j,�,_fl. <br /> afF �61Rf�1Mi�rY �qP K <br /> fl.and f[. <br /> 9.STATIC WATk:R LEVE:L <br /> � ft.Ohel��w Oahove Dale Measured�w�� <br /> — - -"— — ' land surfice <br /> 10.PUMPINGLk;VE(,(telowlandsurface) <br /> (1.afler hrs.pumpin6 �� B�D�m� <br /> � — fl.afler hrs.pum0in6 6.p.m. <br />� — _— II.WtLLHlAUCOMYLETION � �yyy,p�.[`.�� � <br /> �.MR�p <br /> �❑Pitless atlapter,manufacturer� moael <br /> z0 ua:er�eni ornr� �O ni ieas�iz'�eto�e a�=ae <br /> 12.WELL GROUTED? <br /> ❑Yea liNo <br /> — 1❑Nea�('emcnl I❑Benf�inite J❑ <br /> Grout material (rom t�� ft..Cu.Yds. <br /> 13.NEAREST 60URCES OF PO65IHLE CONTAMINATION <br /> �_feet dirc<tion �ype <br /> Welt disinfected uDon complel�on? V<'Q Nn❑ <br /> 14. PUMP <br /> Date insUllcd ��� ❑No�fns�alleC <br /> ManufecturefYName ��� �� <br /> Model Number NP�Volt���t <br /> ��' Length of droD Dipe �4��_ f�.cap�citY Z�_e.p.m. <br /> Material of dro0 p�pe �,�'� <br /> Tyve: �Suhmcrcinlr ���L.S.Turbine S�Neclpnrcat�ng <br /> 2�1e1 <�('enlri(ugil 6❑ <br /> Use a second sheet,if needed I6.WATER wELL CONTRACTOR'S CERTIFICATION <br /> I5.REMARKS.ELEVATION,SOURCE OF DATA,etc. <br /> This well was drilled urtder my jurisdiction and thi:reporl is true to <br /> t�e besl of my knowledpe and belief. <br /> $�� ���.� �i �t��:�f <br /> Licensn Burineii Nnme Licrnx No. <br /> ,,�.�u b2$� �r 1.� �, :`;�g� �l.a�x� �.� <br />�` � SiBned Date ����~� <br /> Aulhotized Represenlative <br /> �C�{� i tBY�t� �"'����t : <br /> Drte <br /> Name o(Dnller <br /> 403760 snoaoM <br /> LOCAL COPY ���6�M <br /> �nesoM <br /> HE-o12o5-ot 2/82 tOM <br />