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STATF�.OFMINNI-:S(IiA UF'.1'AItTMENT01 Hk:ALTH <br /> 1. L()l'ATI()N UI-WF�LL FIlNNFSOTA UN/QUF WE/.L NO. � O���� ' <br /> c���p��� WATER WELL RECORD � <br /> Min taSteN�esI3�A.!)I�.fIX <br /> T��wnsni�Name Tnwnsnip Numher Nen�c Numher Sec1���n N�. I�rec�i��n l. YROYF:RTV NERS NAMk: <br /> N o �a v. v. <br /> B�hG�iR �.�.�," °s`��i w `�J 5�1► 3M � ��i �l�.�4 ,_ <br /> I)Istance and ItHe<li��n h�rm HuaJ In�ersecliuns ii�Sircet AdJrns anJ C'i�Y of Wrll Lt�catiun Addr Sf �� �� <br /> � �� �� ....� ���� <br /> Snow eK�.�l l��c�lion o!well in aec�iun griJ wilh"X." Sks�cA ma0 of well loc�iion. a.W' l DEPTH(completed) Date of Comple�ion <br /> N <br /> ' AJJili�m Namc <br /> _ L _ _ i _ti - ft. <br /> i 5 1❑l'ahle li��i Neverse 7❑nriven 1001)ug <br /> M - � - -•- - - E . <br /> , , � bl�rck Numnn �;{ <br /> y 1�Hn11nwroJ s❑�„ aDe�,.<a ii0 <br /> � — - ' '— '` if�j,. �Ni�tary 6�lel�ed 9�Ynwer AuLer <br /> � , . � 1 <br /> Lol Num�er b. USE <br /> "i' ' __'_ _'i'__"_' <br /> �7n��mrsu< aOv�m��s�vv�r �O i�e�:«Y <br /> $ <br /> F--1 Rttt� 7Olrrlgali��n 5❑Municipal 8❑C'nmmercial <br /> 2. FOkMAT10NL0(: ('OLOH HAitl)Nl�SSOF fk()M TO <br /> IONMATIUN l�Tr�l Well 6❑Air('�rnAili��nin6 9� <br /> +�,� 7.CASING HEIGHT: Above(Below HOLE DIAM <br /> Li�3 �'� '� � I❑Black O�ThrcadeJ � <br /> �.��. <br /> ]0(:alv. S�Welded Surfact ft. <br /> �+�� �e.�y� �M fi� J(+�laStiC 6❑ ����Shoe? Ya_ No� <br /> �Y1' .�,_in.to ��fl. WeiBht �_ly�./ft. �In.to_ft. <br /> �a� � �� �� �K <br /> �n.lo f�. Weitht IM./ft. �n.lo_It. <br /> in.to fl. Wei¢ht Ibs.�ft. _in.to_ft. <br /> ���t � ��. �� a. s��� ,o,�� o�� <br /> Make from ft.fo h. <br /> Type�� Dia. � <br /> y ' �7 <br /> 51�1/Gauz< r� Length <br /> F'ITTINGS: <br /> Se1 befween � ft.and �fl. <br /> f1.and f1. <br /> 9.STATIC WATtR LEVF;L <br /> j� ft.�helnw ❑ahove DateMeasured (*'!�" <br /> - ----- - land sur(ace � <br /> 10.YUMPING LF;V EL(below land surtace) <br />. . ��� <br />. (l.aher hn.pumpin8 B.p.m. <br /> fl.afler hrs.pumpinB 6.p.m. <br /> 11.WELLHEAUCOMYLF:TION .�,�,/�r�.�,.�� ��+�a. <br /> �Q Pi[less atlepter,manufacturer �Y2i.i��taiiiotlel <br /> z0 easemem orr:r� JO Al leaet 12"ebove�,ae <br /> - 12.WELL GROUTEDT <br /> L7ves �tlo <br /> i❑n<��c�m�•�� zOero����ur �❑ <br /> Groulmeterial from to f[..Cu.VEs. <br /> 13.NEAREST SOURCES OF PO6SIBLE CONTAMINAT[ON <br /> �feet direction Iype <br /> Well disinfected upon complet�on? Ves� N��❑ <br /> 14. PUMP <br /> Date in�IW� �� ❑Not installed <br /> ManufatfurelY Name �� ������ <br /> Model Number HHi`'�_Volts � <br /> Length of Arop pipe ��f ft.cap�cllY �j� B.p.m. <br /> M.��.�.i or e�ov v�ve 3�E���. <br /> Type: �Suhmcrsinle 3�L.S.Turbine 5❑Meclprz�cuting <br /> I�Jrt 0�C'rnlrifu6+1 6❑ <br /> Useasecondsheef.ifneeded �6.WATERwELLCONTRACTOR'SCERTIFICATION <br /> 15.REMARHS,ELEVATION.SOURCE OF DATA,ecc. <br /> This well was drilled under my jurisdiction and this reDort is true to <br /> the best of my knowledge and belief. <br /> ..�� '�'��l�i� ���.��i <br /> Littrtree Bu.rineu Name Llcenx No. <br /> �wa.ess��#4 ��.� �� ��'1�t' ��].i2�-� <br /> �""I.1'"'s�� <br />.. . � Signed Date <br /> Aulhorix<d Represenlative <br /> rs�_'s. ___ _ __ Dete��„�� <br /> �o�a� C�PY 4 0 3 7 61 hN'""or orai« sna soM <br /> 7/76 30M <br /> 7/78 30M <br /> HE-o1205-0� 2/82 lOM <br />