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STATF�.()F MINNI-:5f)TA Ok�.YAMiMlNT 04 MF:ALTH <br /> I. I.nl ATI(lN UI WF LL , A1/NNFSOTA UNfQUE WEI.L NO. t. i �� � � � <br /> o���irN��,. WA7ER WELL RECOflD � p <br /> Jor warn somvR ,j. ( � <br /> Minnc.ioto SfeN f[f/SM1 A.11l�.(IM � <br /> T�iwns�ip Name � s ip umner Han�e Numher yec�l��n N�. I�r�a��lli�n J. YROYERTY OWNF;RS NAMk: <br /> � �»�.� S` � w � S�i'� � 84i �i `�11�{'#� (///!��� / ���- <br /> I>isi.nce and ec � fr��m Ho�J Intrrsec�i�ins��r Slrcel AJJress and('ily o!W�II Loc�liun Addresi � . ' I W <br /> � <br /> Snow e,c�c�I��c.�ion nf ell in�ecli���griJ wllh"%." Skelch map ot we111Maiion. a.WF:LL DEPTH(completed) Da�e of Completion � <br /> " i�� �-a�m�:� <br /> _L_ - _' `_'_ " AJJili��n Name <br /> ft. <br /> � � 5. <br /> N - - - - -�- - E i❑c.ni<i����i aOke.r�u �Ond.�� io❑i>�� <br /> i i � tll�ick NumAer <br /> } 2❑Hnl�nwtuJ 5❑Air 6�Bnred 11❑ <br /> ' - - '- '` ��11.. Jf1w�"�+rY 6❑leifed 9�Ynwer Aueer <br /> --. - --�-- 1 <br /> Lo1 Numher 6. USE <br /> iC'��mrs��� ��v�nr s�vv�r �O i�do:„y <br /> $ <br /> r--��.u—� :o�.�,e��,,,� SoM�����o.� <br /> ao��mme.�,.� <br /> 3. FORMATIONLO(: C'OLOIt H�ItI1Nk:SSOF F�H�M TO <br /> FOHMATIUN JOTeN Wrll 6�Air('�rndi�ioning 9❑ <br /> � y,�.,�, i.CASING HEIGHT: Above�Below HOLE UTAM <br /> �},� ��„� �� � Z IODI.ck. aOThreadeJ <br /> �_� <br /> � 20(;alv. 5❑Welded Sur(�ce ft. <br /> `•"+'� �� � �"'� 3�18siiC � DrWe Shoe? Ya_ No� <br /> � �to � fl. Weighl ��.�� I�f./ft. �in.to_ft. <br /> +�Is�y '6�1.i�t I4 25 ,�.�o ��. w<,�� ��,.,�.. —;�.�o—«. <br /> in.to fl. WeiRhf IM./fl. _in.to_(f. <br /> ' ��� b� � � B. SCREEN �]� r open ole <br /> Make� �"�'"^ from ft.ro h. <br /> � IS��Z �8�.�1AF S� �S TYVe � Dia. <br /> Slol/Gauze Length <br /> �t k'ITTINGS�. <br /> ���1 red b 65 ,�r� se�ne�w«�� n.,oe n. <br /> fl.and f1. <br /> L�,, +�g �j��'y 9. STATIC WATtH LEVkL <br /> �� P�V� lE+� i.LSJ R�' fl.❑helnw ❑ahm<� DaleMeasured �^�� <br /> v,r <br /> � �� land surlace <br /> � � � 10.PUMNING LEVEL(below land surfa<e) <br /> �b fi.aher hrs.pumpin6 r�g.p.m. <br /> �t f�.afler hrs.pumpin6 e.p.m. <br /> I1.WI-:LLHk:AUCOMYLF:TION <br /> ��Pilless edaptar,m�nufacturer moAel <br /> z❑ea. e��orr:<� �O At le�st 12"ebove grsde <br /> 12.WELL GROUTED? <br /> ��' l,�'es ❑No <br /> l <br /> i[�or��crmc��� z❑er�������e 3❑ <br /> c�o�s m.«��.i o-om aa «..c�.va:. <br /> 'i: <br /> 13.N�E`AR`E�6Ty 60URCE6 OF POSSIBLE CONTAMINATION <br /> —�fe<t dircetion IYDe . <br /> Weli disinfecteA vpon completwn'. Yes� N��O . <br /> 10. PUMP <br /> - Dale inclelled�+� ❑Nol inslalled <br /> ManufactureiY Name <br /> �� �t�.�4f'�:�. -r <br /> MoAel Numbtt HY�Volis �� <br /> Length of dfop pipe � (1.capuilY B.p.m. <br /> Material o!drop D�D� �^��� <br /> 7ype: �wynmcrcinle 3�L.S.Turbine S�Rrc�prucalin` <br /> ]Qlrl aOc�ro���r�e,i 6❑ � <br /> Use a second sheet,if needed i6.WA7ER wELL CONTRAC70R'S CERTIFICATION <br /> I5.REMARKS.ELEVATION,SOURCE OF DATA.atc. <br /> 'Ihis well was drilled under my jurisdiction and Ihia r<Don u true�o <br /> the besl of my knowledge and belief. <br /> � � V�i 6i��7�'i <br /> Ltcrnser Businera Name Llcen+e No. <br /> - .AdOress �+'�'V +�] :�: �) �+^� +�.Liif L'ii�eb <br /> - ... ... ___...... _ .�.f-r-,-^" ___—_. <br /> � ���� <br /> t � r , Y <br /> Siened f ,/,.�.. ',:F /A��.. . .. . . Date <br /> Aufhorized Representative <br /> 7'�ieic St�s n,c� t�`��� ' <br /> ..p y -- � Name of Dri11H <br /> �.-',.i L t.s,. ��P��l �� `� ('7 ?.y 5/74 30M <br /> 7/76 30M <br /> 'r` �� ,... . ...r.. ...�._. ., 7/78 30M <br /> HE�01205-01 2/82 10M <br />