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.�.�.-�.." <br /> "�"WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. <br /> CounryName WELL RECORD 4 7 9 3 6 � <br /> i�t=�`Cft'i�_-; 11' Minnesota Statutes Chapter f031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(comple[ed) Date of Completion <br /> n. <br /> 'Y'.(',1" 1�3 '/. '/� ' '/. � } "L[ <br /> Numerical Street Address or Fire Number and City of Well Location DRILLING METHOD <br /> , . . ... . <br /> f I Cable Tool C Dnven � Dug <br /> �€>" - ��' , r�r; = Auger Rotary C Jetted <br /> Show exact locatian of well in section grid with'X'. Sketch map of well location. --, �� <br /> Showing propertylines, <br /> N roads and buildings. DRILLING FLUID <br /> I � � ' ;!-; <br /> 'r_ �_ _1 _1_ . ._. . .,..... <br /> � � i <br /> i i i USE <br /> "i' ';' i- �' � Domestic i_ Monitoring ❑ Heating/Cooling <br /> W i � ET r/g'j� �._�Irrigation f I Public '-1 Industry/Commercial <br /> _1_ _1_ __ 1_ I ,r ❑ Test Well .-! Dewatering I_] <br /> I ; ' <br /> ' f-mi. <br /> � , CASING Drive Shoe? Q�Yes ❑ No HOLE DIAM. <br /> --i- �- - -� 1 7 Steel J Threaded - Welded <br /> H—/mile,—� =`j.PIaStIC - <br /> No��7lJ f�t N4�4 .� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 5;'; ' '' <br /> in.to i� :_ft. , :'i. Ibs./ft. �in.to�it. <br /> �.� in.to ft. Ibs./ft. �,�n.ro�. <br /> Mailing address if different than property address indicated above,, in.to ft. Ibs./ft. =in.to ft. <br /> SCREEN OPEN HOLE <br /> . _, VS.��`:�s_.i r�`..�`"_. �.a .t.!�. '� -_... .. <br /> S. w;`; <br /> Make from ft.to �- ft. <br /> . .">A'�r�i L`.ct� :�!i'-' - .....'1 TYPe Diam. <br /> s,. — <br /> SIoVGauze Length <br /> � Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> FORMATION LOG COLOR HARDNESS OF FROM TO ''`'� ft. below ❑ above land surtace Date measured - <br /> FORMATION �. <br /> � PUMPING LEVEL(below land surtace) <br /> ..�_ <br /> ft. after hrs.pumping �c`.i o.p.m. <br /> . � WELL HEAD COMPLETION <br /> �Pitless adapter manufacturer {�Y[�?{-�i,v'r^r'Ce :' Model <br /> j. ' <br /> ._ .. _ . ��; Casing Protection <br /> GROUTING INFORMATION <br /> Wellgrouted? C7 Yes p- No <br /> Grout Material ;_] Neat cement C Bentonite <br /> from to ft. � yds. ❑ bags <br /> from to tt. ❑ yds. ❑ bags <br /> from to fl. ❑ yds. ❑ bags <br /> NEAREST SOURCE OF POSSIBLE CONTAMINATION <br /> feet direction rype <br /> Well disinfeded upon completion? C1-Yes ❑ No <br /> PUMP <br /> J Not installed Date installed �,_.;�--'-`. <br /> ManufactureYs name - .. <br /> :.��1`'—i'�!:''��E? : <br /> Model number HP ? Volts G:'i' <br /> Length of drop pipe �1r,s ft. Capacity � a.p.m. <br /> Pressure Tank Capaciry ��. y : ��. <br /> t: <br /> Type: L1:;Submersible IJ LS.Turbine I_l Reciprocating� - Jet �_. <br /> ABANDONED WELLS <br /> � Not in use and not sealed weA on propeRy? !' Yes ��, No <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdication and in accordance with Minnesota Rules,Chapter 4725. <br /> The information corrtained in this report is true to the best ot my knowledge. <br /> Use a s��eet '/n ed L:�. ' __x�1_i', t _ L�s`�1 i 3�ti(:; �. a t',w- f i ' <br /> M <br /> REMARKS,ELEVATION,SOURCE O A A,etC�''"- Licensee Business Name Lic.or Reg.No. <br /> r r n � -._ ''� <br /> sv°` % i �7�""^r,-. <br /> i,; <br /> ,. .f f�! � %r � �-� ,:-�: ;--�:�:� <br /> - ` �'� Ali�hohie�Repiesentat�Je S�ganture Date <br /> r, <br /> � � :'f`� k ,:t?2' .. -�L <br /> Name ol Driller Date <br /> LOCAL COPY 4 7 9 � � � HE-01205-03(Rev.9/91) <br />