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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> � -- WATER WELL RECORD M/NNESOTA UN/QU6'WELL NO. <br /> Ccunty t'vame� Ja.Wa��Sa■.p/e 4 6?� � �J <br /> ��E,nne ln Mi��aom S�arrics(56A01-.08 <br /> Townah�p Name�� ownsh�p Num Range Number Sectan No. Frxuon G. WELL DEPTH immpkted) Date o(ComD�etron <br /> Orono 117 S 23 w 18 NE �' NE� Sk'�h 68 r�. 1/19/90 <br /> Numencal Sticet Address and City of Well L.oca[ion or D�s[ance from Road Imersecuon. 5. DRILLING METHOD � <br /> ❑Cable7ocd ❑Reverse ❑[hrvm O DuQ <br /> n � <br /> ow exact bcatan d well m sectan gnd wnh"X." Sketch maD d well lonf an. O HollowKod O Air O Bored ❑ <br /> N <br /> � i Addiuon Name $1 Rotary OJetted p Power Au�{er <br /> --r- t -1 1- 6. DRILLINGFLUID <br /> i <br /> ' ' � � Bentoriite <br /> ._�- --- �_ �_ BbckNumbrr <br /> W � i E 7 USE <br /> -1- -1 � I�[bmestic ❑Mon�tonng ❑Hcat Pump <br /> I � � La Number ❑Irr.gatan O Pubhc O Industn <br /> ' � 4.,rni. <br /> __�_ ; � � � �l-est Well O Munlnpal ❑Commercial <br /> 'i- - -r- ❑AvCondiuonmg O <br /> I <br /> - 1 �Ir—� 8. CASING HOLE DIAM. <br /> 2. PHOFERTY OWNER'S NAME Mailing Address if diiferent than propenr�address ❑Black HEIGH7-:Aho�c�Below <br /> O Threadcd <br /> ind�cated above. Surface (i <br /> Scherber Properties P.O. Eox 8 ��a�� ❑Kelded , <br /> Dnve Shce. Yes— No-_. i <br /> Excelsior, riN 55331 �P�asuc ❑ <br /> m.tu ft. Waght IEs.�ft �a io�i. <br /> HARDNESti OF <br /> 3. FOIiMAT10N L(� COIAR FROM TO _m.to ft. Weight _Ibs.�(t ._�a �o-1t <br /> - -_, FORMATION I <br /> ----- .. in t„-_..-_... (t. N'e�kht- ---IbsJ(t. �n. tn-�c.! <br /> To �oil Black F'rost 0 ? 9.sceFen u����n��� <br /> (rem (t.to. ft <br /> Make - <br /> Yellow Clav Yellow i�]ed. 2 30 TY� �ram — __ <br /> siovea�Ze 13 slot ���,n_ <br /> Sandv Clc3 � �—(t.and�S�f! FITTINGS <br /> Red "ied. 30 33 �'�''w�^— <br /> 10 STATIC W'ATER LE'.'EL <br /> Clav Gr.av I Med. I 33 5Q 41 _f� o�:�w Gebove DaceMeasured I <br /> -'—� j� land surtace v _`__� <br /> I !i. PUMFING�\�E��bebw land;uriacei <br /> Gravel �Iixed �ft 5C� 52 � <br /> � . µl ft.attrr_�hrs.pumpmg--� — R.p.m. <br /> ft.a(ter_ hrs.pumying g.p.m � <br /> Silt�' Sand Gra�' i Med. 52 �7 IP. HEADW'FLLconsv�e�ion iR.�_ <br /> �Pi�less adaptrr manufacturer `�'llt-ehdtei__Model j�i�.� I <br /> I <br /> S3R�i B�.BCIC 5^ 68 OBasementofiset ❑At least 12"abrwegruund <br /> L7 Piasuc casing protecuon <br /> -__� <br /> 13. WELL GRUUTED? 61 Yes O No I <br /> ❑Neat Cement O Bentom!r U— - � <br /> Portland 0 30 ' I <br /> Grout matenal— irom_ to -(t.cu.yds—�_ <br /> Bentonite 30 52 �__ I <br /> I4. NFAHEST SOURCES OF POSSIBLE CON7AMINATION <br /> �.Sd.L(eet C d�recuon T akP �rvpe <br /> Well dis�n�ected eqm completwn'' (�Yes ❑No � <br /> I� PUMP � <br /> llate mstalled 1/2�/� C Not mstalled <br /> Manufacturer's name Cp In(�friS _ <br /> Modrl n�mber Gr>>nc�f�S _ �v3,�1�vous )?�'; <br /> Length of droP qpe-- �� �t. Capaaty �O g p m � <br /> Matenal uf drop p�pr�V�lI11Z� <br /> Type: IXSubmersibir ❑L.5 T�rbme L]Heaprocaung <br /> UJet ❑Centnlugal ❑ __ __ <br /> 16. Af3ANIWNED W�LLS <br /> linused well on property' �Yes ❑No <br /> Usr o second sheel,i/needed �� � Permanem ❑ 7 empprary ❑ Not seakd <br /> 17. REAtARKS.ELE.VATION,SOURCE OF UATA,etc. <br /> iH. WATER WELL CONTFiACTOR CERTIF�ICATION <br /> 7�his well was drilled under my 7unsdicuon and[his repeMt is trur to the bes�of my <br /> knowledgr and behef <br /> Ber�erson�'-as�ll Inc. ?7�5� <br /> LIfP115PP HNSl�IPSS A'OTP L��eKv hb. <br /> Address 5115 In rial Street :`'Ia le � �'�V 55359 <br /> �f � �� � <br /> S�gntd L^ _�_ Z-v[��1•����'�DatP - 19/7V <br /> Authorizrd Hepresentattue <br /> Ir3LT�\' SC�IIII1Cit Dace�1� <br /> 14nme•ol fJ�t!!Pr <br /> IfUPORTANT: , 4 6 21 �' � �, 5%�e� <br /> FII F 11!ITH f�FFfl — l4�Fl i (141%nFR C(1PY � z ,.,,.,�,,,,�.._ .,„,�, �;7e�' <br />