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STATE OF M[NNESOTA DEPARTMENT OF HEALTH <br /> 1 WATER WELL RECORD MlNNESOTA UN/QUE WELL NO. ����O� <br /> Coun[y Name <br /> �7 w ti Il c p 1 fl Minnewla Sfatrfes 156A.01.08 /�warp.somae <br /> Townahip Name� ownship Number Range Number Section No. Fraction 4.WELL DEP7'H lcompktedl Date o(Completion <br /> Or�r,o 117f3 ° 23 W w 7 SE ��SE ��NE�� i 8� r, i�.rR��: 27 , �991 <br /> Numerical Street Addiess and Ciry of Well Lcea[ion or Distance from Road Intersection. 5.DRILLING METHOD <br /> ,�,Q3•7 �a�•1� R��'., �Y•DI'��� MM ,.�]�36`� ❑CableTool OReverse ❑Driven ❑Dug <br /> ow exact location d well in sectbn grid with"X." Sketch map of well location. �HollowKod ❑Air ❑Bored ❑ <br /> N <br /> � � � i Addition Name ��.1 Rotary ❑Jetted ❑Power'Auger <br /> _� ~ _1 -1 6.DRILLING FLUID <br /> � � Biock Number g�.�Q 1 'C'` �`Li 1 Y' �"��'1 <br /> --�- - � <br /> w i �� �- �- <br /> � . E 7. USE <br /> i <br /> _I_ _s_ _� __ ;�[}�Domestic ❑Monitoring ❑HeatPump <br /> � � f�mi. ��Number ❑Irngation O Public O Industry <br /> ' � � ❑Test Well C]Municipal ❑Canmerciai <br /> i � —r' j ❑Air Conditioning O <br /> I �m��—� B.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address ��B�a�k HEIGHT:�Iow <br /> -''�J Threaded �_„�,� <br /> indicated above. Surface tt. <br /> ❑Galv. ❑Welded <br /> Don ..S���c�, �� Drive Shce? Yes�No_ <br /> ❑Plastic ❑ <br /> t' 1 � � ?� <br /> } ��.�o �Q u. wc�gn� �' in�.ir�. ��. c4r.r„1�. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to fL Weight IbsJft. �n. to�t. <br /> FORMATION <br /> in.[o (L Weight IbsJ(t. �n. to-It. <br /> ��.Gy Sc ::c".��.i �`•r�T.J�? :^i� � �FJ 9.SCI�EN Or�openhole <br /> ��G}1�'2SOF1 trom tt.to. ft. <br /> Make 7 y. <br /> �`Z^�� jrC3 vaf� C7� 1C�,'L� Type '�tt�1.�1.1���J' ..�.'aL:.�tyl Dlam. 41� <br /> `' f t . <br /> SIoVGauze a 1'�t Length � <br /> san� & clav ��r�wn ^oft 12� 1.`_.8 3 ft . �xtn�'�Ti"c�ii <br /> � Set between f[.and it. <br /> ]0.�"I�'�f WATER L <br /> c i a y � s a r.r� ��r��I :3 c�f t �,�',$ ��� ft below O ahove Date Measured ��7 7 <br /> land surface <br /> ^� 11.PUM�ING LEVEL(below I d surface) �O <br /> £it�n'�i fJc l:1�i;� :�r a.y ¢?�.i r"�" ��6 � !�..'- .� (t.a([er � hrs.pumping g.p.m. <br /> ft.after hrs.pumping g.p.m. <br /> s�G1 1T'c�Z �=j I e�Y � rC� �L7-� ��`1 12.HEAD WELL COMPLETION t � L!�� <br /> `�Y tless adapter manufacturer �Q�1�0 r Model ��_-� <br /> iBasemen[otfset ❑At least 12"above ground <br /> Plastic casmg protec[ion <br /> _WELL GROUTED? ��'Yes ❑No <br /> ❑Neat Cement �Q Bentonite L7 ..— <br /> Grout material from to tt.cu.yds. <br /> �PR 2 2 19.., -- <br /> ]0.NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> '�� (eet S direction 1 SI�1'�E� ?i Z Li2!11;1 l"2C� <br /> �C� ;YPe <br /> Weli disintected upon completion? E'Yes ❑No <br /> 15. PUMP n <br /> Date installed `'/?7 ❑No[installed <br /> Manufacturer's name A2 rtna t o r <br /> Model number HP J��Vol[s L'�� <br /> Length ot drop pipe tt. Capacity 1� .g.p.m. <br /> s e�l <br /> Material of drop pipe _._ <br /> Type: C�6ubmersible ❑L.S.Turbine L]Reciprocating <br /> ❑Jet ❑Centrifugal L] <br /> l6. ABANDONED WELLS <br /> Unused well on property? -'t7 Yes ❑No <br /> Use o semnd sheef,if needed �� C��Permanent ❑ Temporary ❑ Not sealed <br /> 17. REMARKS,ELEVATION,SOURCE OF DATA,etc. � <br /> 18.WATER WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdiction and this repor[is true to the bes[of my <br /> knowledge and belief. <br /> T,(?LUttiG"lE'r' W`l I ITt� , IL�i.!,�.� <br /> V i��5�"i'�5"°'��!n 5 5�8 6 License No. <br /> Address <br /> n <br /> �+ <br /> Signed Date <br /> �`1 �J C�:iZT!���ori2 Representa[lue �/� ���z <br /> Date <br /> Name of Drtfler <br /> LOCAL COPY " ' ' S��4� <br /> : '� �` <br /> ms� <br /> ': `� � �'_ `; ��'k HE-01205-03(Rev.9/88) 2iez�o�i� <br />