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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. <br /> CountyName WELL RECORD 5 4 8 5� 2 <br /> �E'LIT2E.';JII�t Minnesota Statutes Chapter 1031 <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> C,�rc�a 117 �' G� ,. �. �. 1_•;�9 11-1 t�--��. <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> L�6,(? ��r R�lI2 �C�1.1 Q�i.�U� �Cl. ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger � Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ <br /> Showing property lines, <br /> ry roads and buildings. DRILLING FLUID <br /> � i <br /> --�--�- -1 -1- ��L F�r.; . <br /> 1 �4- <br /> i � i X ,USE ❑ Heating/Cooling <br /> � a{pomestic ❑ Monitoring <br /> yy i ; i , E ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> _1_ _1_ __ __ T ❑ Test Well ❑ Dewatering O Remedial _ <br /> I � ' <br /> �'^1° CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- �- ; -r- j ❑ Steel ❑ Threaded ❑ Welded <br /> � � <br /> I ��� C�Plastic ❑ <br /> � I milr� �.�AJ <br /> ���c r� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.to �3t�n. ibs.in. � ��� ~l` <br /> ��:n. <br /> �C.'�i.�G'� t�I��ct �7ri.�1�7 in.to ft. IbsJft. � �`n`t� nr <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./tt. V i�{,to���V� <br /> '$��� �� S��� 6y,��,� SCREEN OPEN HOLE <br /> nca Make�T�s r_� n from ft.to ft. <br /> 1'QP•YI �'c711'1� �tt.�::���'i ���� <br /> � Type Diam. � <br /> SIoUGauze l � � � Length C`;� <br /> � Set between 1�f: ft.and '1 iA ft. FITTINGS: <br /> �� �✓— <br /> srnricw�r�F}�L€VEL 'iF��_y� <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO t ft. �below ❑ above land surface Date measured <br /> MATERIAL <br /> . PUMPING LEVEL(below land surface) <br /> (�lci� J Lp� t�j(j� ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION r.a.' <br /> �`�� S (�'�j 1 �S�}C �?Pitless adapter manufacturer T��-���� Model <br /> ❑ Casing Protection __ �12 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> Grout Material ❑ Neat cement.�Benropjt - <br /> from �' to �'�� ft. � ❑ yds.� bags <br /> from to ft. ❑ yds. ❑ bags <br />„�,,,., from to tt. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> � <br />- r�� feet <_. /�..`.� direction -��!���.:L type <br /> Well disinfected upon completion? ❑ Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed `" `"�''��' <br /> Manufacturer's name ��L'�:1:Y>�C%� <br /> Modelnumber '��(,(j•_�}L; HP �5; _ Volts L_5�i" <br /> length of drop pipe tt. Capacity �?j r g.p.m. <br /> Pressure Tank Capaciry �1c�. � '�"1C�� ��•i�7 <br /> Type: � Submersible ❑ L.S.Turbine ❑ Reciprocating C Jet � <br /> ABANDONED WELLS Y <br /> Does property have any not in use and not sealed well(s)? ❑ Yes LT 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,il needed �� ��� ���� ����7 �.� �.�. l!� l 2 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. /Licensee Business Name Lic.orReg.No. <br /> //////����///// �"�l' 11—ifi-94 <br /> ���" �%� <br /> M AR �J �- A� Author¢ed Representative Signature � Date <br /> 1995 P.�. �'��:�i�can i 1-18-9 <br /> Name of Oriller Date <br /> LOCAL COPY � 4 8 5 4 2 HE-01205-04(Rev.5/92) <br />