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� - _ <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CounryName WELL RECORD � � � � � � <br /> ���)j,� Minnesota Statutes Chapter f031 <br /> Township Name Township No. - Range No. Section No. Fraction WELL DEPTH(completed) Date ork Completed � <br /> L�TY?l'ft�+ � � f d� {�� y. v. v. �a� � i-'n-'�`� <br /> Numerical Street Address and City of Well Lxation or Fire Number DRILLING METHOD <br /> � Cable Tool ❑ Driven ❑ Dug <br /> `'���'� � P' i�`"' �f���� ❑ Auger �,Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X'. Sketch map of well location. ❑ <br /> Showing property lines, <br /> N �y�'' roa�,apd buildings. DRIILING FLUID <br /> I � _1 _1_ ./7' �' .�.'.[��.i�'r'1#'.k^a <br /> --r- ti- � i J��Y <br /> i � i Yw ,USE ❑ Heating/Cooling <br /> _�_ ___ �_ �_ � �� �, �1 Domestic ❑ Monitoring <br /> yy i ; i E ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> _1_ _1_ __ __ T ❑ Test Well ❑ Dewatering O Remedial <br /> 1 ' � ' <br /> ' h mi. CASING Drive Shoe? jt�Yes ❑ No HOLE DIAM. <br /> --�- �- ; -r- I r[7 Steel ❑ Threaded � ❑ Welded <br /> � ' 1 � <br /> ❑ Plastic ❑ <br /> F—I mile—� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME e.". ���"+ Z i'.FE� "/ � <br /> in.to ft. Ibs./R. /.� <br /> - �in.to��ft. <br /> �.�.`CsY't�r �.`l�@.� E.�:�1if�L�.%'":y in.to ft. Ibs✓ft. in.to! � ft. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. _in.to_ft. <br /> SCREEN OPEN HOLE <br /> � Make .7f3�'tY!�':CiYd from ft.to ft. t <br /> TYPe4'�+-�, . .�Y���,�3 —Diam. n - <br /> .�cc-�..t����'1'��.'�l`r7 <br /> 4�liti ���..4ILZ.Y� �.�1?��. SIoVGauze ,�. Length LJ,�_ <br /> D������ �� cjr�Li;�ti Setbetween ft.and it. FITTINGS: <br /> STATIC WATER LEVEL <br /> HARDNESS OF _,� � �;, <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � ft.}�] below ❑ above�and surface Date measured .�-�-._ <br /> PUMPING LEVEL(below land surface) <br /> ��,, �� 'q; } ft. atter hrs.pumping g.p.m. <br /> WELI HEAD COMP�ETION <br /> i� li;e �r;i, r� pitlessadaptermanufacWrer ���t���s���� Model <br /> 4.:1� - & .;:�It� <br /> ❑ Casing Protection 7�] 12 in.above grade <br /> �-ti A:�,, & (i3-�-�%Yn� ,,i'� ��;� � GROUTING INFORMATION <br /> Well grouted? ❑ Yes Gj,�No <br /> Grout Material ❑ Neat cement ❑ Bentonite <br /> from to R. ❑ yds. ❑ bags <br /> from <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type �� <br /> Well disinfected upon completion? �Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed �^G�'i �'�!�' <br /> Manufacturer's name 1'�VE'�'S <br /> Model number HP � Volts "�''�j� <br /> Length of drop pipe � lft�. Capacity t��z �r g.p.m. <br /> Pressure Tank Capacity V ti� �uC:37 �.i-1�.E'.�& � <br /> Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes f�No <br /> _ "� � WELL CONTRACTOR CERTIFICATION <br /> y A �„ �� This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> � L The information contained in ihis report is true to the best of my knowledge. <br /> Use a second sheet,i/needed � �C�.i�'��j�{:y �r��T� ���p.� �}�� �.��� G���� <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name Lic.or Reg.No. <br /> �"%�� '. - , <br /> �-�.-�13 <br /> �- <br /> 7�thonzed RepresenhaBve S�gnature Date <br /> 0�+�'_ _ Bi1I Ii..i<j<� �-�`-�� <br /> � f <br /> yi <br /> � L=�'�'i � � Name ol Driller Date <br /> ! <br /> LOCAL COPY � ��5 �6 HE-01205-04(Rev.S/92) <br />