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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ��� WATER WELL RECORD MlNNESOTR UN/QUE WELL NO. /� ��C � H <br /> . CauntY�M Mr��esola Sfatrta/56A.01�.08 /�Wafn Soinple �'� U <br /> ownship Name� ownship Numbpr Range Number $ection No. Fraction 4.WELL DEPTH(comple[ed) Date of Completion <br /> �i�t"3�i(� i 1� ;_«" 23 " ' 3:� !���' "��.� SC�� L41 r�. �� i�t3�t t3� <br /> Distance and Direction fran Raad interxction w Street Address and City o(Well Location 5.DRILLING METHOD <br /> �� ����t,'„� t�.��� r���� ���#„� ti}�,��� 1�Cabk tool 4O Reversc 7C]Driven 100 Dug <br /> i €� RG <br /> iow exac[lacation d well in section grid with"X." Sketch map ot well lorrtion. �Hollow rod SO Air 8L]Bored 11❑ <br /> N <br /> - � � � i Addi[ion Name �.�_�„� �:ip Rotary 6O Jetted 9O Power�auger - <br /> _� � _1 _1 ti 6.DRILLING FLUID <br /> - , ...__� _. �€t�Tt�#tiTE DRILL t�� _ <br /> --�- '1_ �_ �_ Icek Number R � .:f.:- . <br /> W i ; � E � 3�"'<.4 ;�::_ . 7.USE <br /> _1_ _1_ _'_ __ : '� lO Domestic 4O Monitoring 8C]Heat Pump <br /> I ', � � I Lot Number � ! q�� � �� �Imgation SO Public 90lndustry <br /> f mi. <br /> � i I : �""� } 30 Test Well 60 Municipal IOO Commercial <br /> --�- �- � —r- 1 } � �""""""�--�.R......._..�:.+ � � 70Air Conditioning II❑ <br /> � /rMik'—� �� ' 8.CASING _ HOLE DIAM. �� <br /> 2.PROPERTY OWNER'S NAME HEIGEJT:Above�ffelow <br /> 10$lack qp Threaded � <br /> t YTV ffL � - Surface ��� tt. <br /> a��� �' 2O Galv. Sp Welded <br /> Address �{,(�}� �'�� Drive Shce? Yes_No— <br /> L 3O Plastic gp <br /> GKT�FxLt �Y 1 �� 3���� �in.to�tt. Weight�S�Lal�Ibs./(t. �n. to�t. , <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight IbsJft. �n. to�t. <br /> FORMATION <br /> in.to ft Weight IbsJft. �n. to�t. <br /> 9.SCREEN Or open hole <br /> rt A V AnY �Au C ��{ Make from ft.to. ft. <br /> bi.A f flA� Ai{ J V <br />� . � TYPe r=vrnz����� e�rrr� Dis. �p�_ <br /> rt p V 1'ttya� i Ey 7� SIoVGauze—an t�•+} �� FI� ,�NGS: <br /> rri.tt� tiE��1 �V aNJ <br /> Set between�ft.and�—tt. <br /> C�Y WLrt� �3 IU 10. STATIC WATER LEVEL <br />� �ft;D below ❑a6ove Date Measured��i �7 <br /> land surface <br /> ��� �� 7,j ��� 11. PUMPING LEVEL(below iand surface) <br /> �ft.after�, hrs.pumping �.f'�_ g.p.m. <br /> ��� ��� �� ��� . t[.atter�_hrs.pumping �� g.p.m. <br /> I2.HEAD WELL COMPLETION <br /> /�1 h y /•p/i V l i;r?� t ftrl SD Pitless adapter.manufacturer T����� model�� <br /> 46n F UiE�T1 i f t1�4J i FV 20 gasement otfset 30 At least 12"above ground <br /> 4O Plastic wsing prolec[ion �R <br /> ���q{� t � /�y p�p�, �} r <br /> il�SFf i�� f CL!!i �w's�I�� � G�� 13.WELL GROUTED? <br /> T�y� t D Yes ❑No <br /> IiV�i�� i/�5A G�7V GJ� 1�NeatCement 2C1$entoni[e 3O <br /> � -���--- �- -a1ti� <br /> Grout material trom to ft.cu.yds. <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> .. ------` ._ _.. , . ' <br /> feet �_direction S type <br /> Well disintec[ed upon completion? �Yes ❑No <br /> � <br /> 15. PUMP <br /> � � � Date installed h�{�*�7 ❑Not installed <br /> Manufacturer's name r"��— ;�� <br /> Model number�TL. Y:�! NP�_Volts� <br /> Length o(drop pipe—�� ft. capaci[y—9�g.p.m. <br /> J <br /> . __ Material ot drop pipe - <br /> Typet-7�kSubmersible 30 L.S.Turbine 50 Reciproca[ing � <br /> •t <br /> 2OJet 4�Centrifugal 6O <br /> 16. EXISTING WELLS <br /> Unused well on property? �:S�es ❑No <br /> Use a second shnt,if needed <br /> 17.REMARKS,EIEVATION,SOURCE OF DATA,etc. Abandoned �'{�r'Permanent❑ Temporary O Not sealed <br /> • 18.WATER WELL CONTRACTORS CERTIFICATION <br /> f�i s I s �(i4 s��.��d� ��� Q� L�a L� ��t 6 ��� This well was drilled under my jurisdiction and this report is true to[he bes[of my <br /> rras �cradtrert.e�tl�t rtti�d by ��tt1n9 ttie s�reep. knowledgeandbeliet. <br /> Seca�nd +r+�11 �s l�ft north afi' t�t ]�t r�e11. � t <br /> an � <br /> ����Liceusee us�nu�cs Name�� �• Lrcense Na. <br /> r <br /> Address_ <br /> � R , <br /> `�t...:,� r' .* <br /> Signed i• .�,.':.f ' ... = Date��'�y f <br /> - Authorized Re resenta[ive <br /> DatP 1-���] <br /> ��� �a� iller <br /> 5/74 30M <br /> 7/76 30M <br /> LOCAL COIPY 4 316 4 8 �,�8�, <br /> HE-01205-02(Rev.10/85) p�gp�q„� <br />