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titATF()F MINNF�.S()TA UF.YANTMl;NTOF HF:ALTH <br /> I. L()('ATI()N UI-wl LL MINNFSOTA UN/QUE WE/.L NO. M �.�� � <br /> c�����r N.��< W A 7 E R W E L L R E C 0 R 0 � Wa� Samp�� s� <br /> ��� � Minn raS�alutnlSnA.rll�.rlx - Y � <br /> !'i�wn�hip Name Tnwnship Numher Han�e Numher y�c��i�n Nn. I�r�it���n 3. YROYERTY OWNERS NAMk; <br /> t3�ras� I27�i 5� Z3i� W 33 n� '`se '` e�y P er�sse�- - �'�L-�-� <br /> IlislaniC an�It�Ke<I���n fr�rnl 12ir�J InterSecli��ns��r Slreel A�Jress anJ C'�IY o!Wtll Lncal�un AAdreii� �yr�'1'��Zr��.�� �� <br /> ����I M� It riiii _ <br /> ��e,-� -g53S� <br /> Sn�iw eu��I��ca�iun nf well in.ecil��n griJ wi�h��%." Ske�ch map of well loca�iun. 0.WlLL DEPTH(completed) Date of ComD�elan <br /> N ��� <br /> -L ' ' ` - AJJ�lii�n Name xw�'�7 <br /> ' - " fl. <br /> � � � 5. <br /> W -' ' ''' -I' - r 1�('ahlel����l 9❑Heverse 'I�nriven IO�i)u� <br /> i � + i � bl��ck Numhet <br /> y 7OHiNInwrv�J SOAIr 8❑Bnred II❑ <br /> ' - '- '� 1}Illj,. �Il��t�rY 6❑Jelled 9�Ynwer Auier <br /> I ' ' I I,ol NumAer 6. USE <br /> '_L "''' __ _"_'__ � <br /> 1 <br /> I�/nmexlic a❑YuAlic SupplY 7�Induslry <br /> S <br /> �—1"nU zOtr,ce+�+��n sOntun c�o+i m�rc <br /> eOc�m �.i <br /> 1. FORMATIONLO(: ��p�pH H�NIINF:SSOt F�HOM TO , <br /> t()NMATIUN J�irs�Wrll 6❑Air('��nAili�inin� 9❑ <br /> ].CASING H61GHT: ADove/Below HOLE DIAM <br /> �R� e��� i..4�..5,. !'�i � I�tllack 0❑ThreadeJ <br /> 1 av #ri�.l:tC. �! <br /> x�G�lv. 5❑welded Surface fl. <br /> ���p 4�j� � �� �❑Plastic 6❑ a��e Shoe? YG_ No d_ <br /> + � in.to ��� ft. WeiBht ��y� Ib�./ft. �In.�h. <br /> �rl$�I �31� 3� 37 ��.�o rc. w��sn� ma./e. —��.�o_rc 5 <br /> in.to It. WliRht IM./(I. _in.f0_h. <br /> C��$�� YIFY�b�, �� �Z B. SCRE�„��' ropen ole <br /> IYQMi� from f[.t0 ft. <br /> Ly /�� �^ ab <br /> ��j�-_'�+ $a. VJL F7� TYP� �JCt �L� Dia. � f <br /> SI�I/Gauxe - �� � Lmgih ^� <br /> ''�'}; '�''j� F'ITTINGS: <br /> ,�y�t,� �� � ��� Se�6etween �fj (t.and j�f1. <br /> Sf1R1a <br /> . � t1.and !t. <br /> .,��t� �1 ♦ L� �fs� 1� 9.STATIC WATF;R LEVEL <br /> iii�i�'���i �i'�"'it IO LY� 9� .. n�ei�,w ❑ano�e o,��Me.auree ���� • <br /> ..-- -- - lands'udace <br /> ��������� ��� S jy�] T�� 10.PUMYING Lk:VlL(below land wrface) �� <br /> i�ll � <br /> (t.ah<r Ors.pumpin6 8.p.m. <br /> ft.afler hrs.pumping g.p.m. <br /> 11.WF;LLHEAUCOMYLETION <br /> _ — � <br /> n s � iC.�+��esseaapie.ma��ra�wrer ,,,odei <br /> . „ � i` ��� L� \ � I�Basement of(scl �AL least 12"ebove grade <br /> - � _S <br /> - -"� �� 12.WELLGROUTED? <br /> �kc ❑No <br /> .. . . — I�l`al('emcnt 2❑B<n���niie 3❑ <br /> Grout material from ft..Cu.VAs. <br /> ` �� <br /> t �-. <br /> -'"'�� 13.NEAREST 80URCE6 OF POBSIHLE CONTAMINATION <br /> � ""� ��feet direction lype <br /> Weil disinfecfed upon complel�on^. Ves�' Nn❑ <br /> 14. PUMP <br /> Daee in:ull<A ❑Not installeA <br /> ManufacluretY Name �� 'gr� l <br /> Mod<INumber HY � Volts� <br /> Length of drop piDe � � (t.cap�city�� g.p.m. <br /> Materinl of drop pipe �F� <br /> Tyve: i�unmcrsinir ��L.S.Tulbine s❑Heclpn�caling <br /> 301rf 4�C'rnlrifueal 60 <br /> Useaseconasheat.ilneedad �6.wATERWELLCONTRACTOR'SCERTIFICATION <br /> 4RKS,ELEVA170N,SOURCE OF DATA,etc. <br /> This well was drilled unAer my jurisdiction�nd thi:repon is�rue�o <br /> the best of my knowledge and Eeliel. <br /> �tt3Ye�S �Tla,21 C0 �1.91a <br /> Liceluee Builneu Name Llcrose Na. <br /> ,,�� bz�� � �.� �r,��,z� ��, � <br /> --......_. ____ ._� :, <br /> Si{�ed � � - Date 1'�y Y2/ <br /> Aulhorized Represen�alive <br /> , �.$ ��YS u.c�l—�f—�� <br /> R.'�,.+"«PRL C\.'�� ..y' .{ � �j +`�� NameofDrdlet <br /> 5/7d 30M <br /> 7/76 30M <br /> J <br /> '�-'�- 'a%��t .'-� �--- 7/78 30M <br /> HE�01205-01 2/82 10M <br />