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_ ,.<,, . .. .. . .. .. . . �. . _.... _ . . . .. .... ...:. . �-- ..� . . . ... ._. .e. ..... .. . .. ... ._ . . . . .. � ._ WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. ;,nuntyName WELL RECORD 5 613 9 6 �t":i'.*IE`_i,.L'; Minnesota Statufes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. �, �.�: C�'..�C: , i � f�:' v. ��. v, r _ _ _ Numerical Street Address and City of Well Lxation F or Fire Number DRILLING METHOD t ❑ Cable Tool ❑ Driven ❑ Dug ..��:� f.aE:'E:1� �'�1..13�1 `��i�c':7..t L{J}15..� Ia31LE„' ❑ Auger ❑ Rotary ❑ Jetted Show exact Iceation of well in section grid with"X". c�.:.w.. - Sketch map of well location. ❑ �=-'��' Showingpropertylines, ry �afid buildings. DRILLING FLUID i i ��:: �. �„r.. I � '� _r__y_ _1 _1_ _ i � i � i � ,USE ❑ Heating/Cooling ._+_ ___ �_ �_ p,l Domestic ❑ Monitoring W � i � E ❑ Irrigation ❑Public ❑ Industry/Commercial ' � ❑ Test Well O Dewatering � Remedial _1_ _1_ __ 1_ ❑ � ' � i I t' � �""'�� u� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. t --;- �- -� -�' j � � ❑ Steel ❑ Threaded ❑ Welded � � I�:1 Plastic ❑ F-1 milr-� .... �------'--'-^..-... CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME �� t�r' � . : in.to �✓�:ft. Ibs./ft. �i_j f^ita ��ft, t'�'`..-:�t ��''t'f3:.� _,. C:�.t-f��.��;:�.% in.to ft. Ibs./fl. -�ip.a0�_h.� _. Mailing address if different than property address indicated above. in.to R. Ibs./ft. in.to_ft. �.. j°: J r7L� !�t� a -:'. '�i.-. r`�E� �� SCREEN_ .. tIr OPEN HOLE C I.. � �Al. ..�Ji i j:J.!-�j-1 j�?"� �tf�� J-.� � � , 4Make from ft.[o ft. . 7ype =.=+.'�.-..i-j11.E.'�'aS :3��.,'1 Diam. �+:; SIoVGauze E! ��j+��• Length � !. a Set between _ 1T,,�R.and '" �_1 rt-�S> tt. FITTINGS: STATIC V�AT�RtLEVEL GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO ft. C�-below ❑ above land surface Date measured {'-' -;�` MATERIAL - (.��-�,: � i �, i PUMPING LEVEL(below land surface) ` R. atter hrs.pumping g.p.m. � - WELL HEAD COMPLETION �L{t� ` i}t'� �l'i��-'` �1 Pitless adapter manufacturer �`�:�J_�£�Yt .�:+",ti?i_� Model ❑ Casing Protection �}12 in.above grade ��.j.:.:�X� . '�,,.� p '�r,,�.7 z "�� GROUTING INFORMATION Well grouted? E�Yes ❑ No ��1'f� . 1: ;,r -- .. ��_�7;' Grout Material ❑ Neat cement k�Bentonite from__�_to�_ft. ❑ yds.II bags from to ft. ❑ yds. ❑ bags from to ft. O yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION .��J � feet � i t �� direction �f�� /� type Well disinfected upon completion? (�'Yes ❑ No PUMP j �... j ."._ � ❑ Not installed Date installed - � � Manufacturer's name � � � ` � � � � Modelnumber HP ��- Volts Length of drop pipe � ft. Capacity 1 g.p.m. Pressure Tank Capaciry � � � - � � Type: t7 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet O ABANDONED WELLS Dces property have any not in use and not sealed well(s)? ❑ Yes Q`No WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. � '� The information contained in this report is true to the best of my knowledge. � .�:. . ..--� �� ,� . .._ ��r��.�,.�, ti,u�_,x, r�E��T�i..;_�.�G "_ . IR��. : 1i2 Use a second sheef,ii needed � �� ! - REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Na e Lic.or Reg.No. i -- � �� , _�r:: qN 1 1996 �-� •'�� Authoriz' epresentatiy� /gnatu�e �--"� Date .-; 1`.�'. �'O,=T�k,_r+��ri (` _C. Name ol Driller Date LOCAL COPY 5 613 9 6 HE-01205-04(Rev.5/92)