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��7ELL'LUC?�,TION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> �o��ty Name WELL RECORD ��6 4 � 6 <br /> I3es�ne�i.n <br /> Minnesota Statutes Chapter 7031 <br /> Township Name Townrysh-ipp No. � Range No. Section(No. Fraction WELL DEPTH(completed) Date Work Cotmplete-d7 (_ <br /> 11.L�G 1 1 ! L'.�J �Lt � ��.� ry. � }'—� I'�7� <br /> /. /. /. <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> '��J� �5��[7e �•'�j� Crr���� �. ❑ CableTool ❑ Driven ❑ Dug <br /> � ❑ Auger ��Aotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> I � _i _i_ �P.I3i.t)I�2���G <br /> --r--7- i i <br /> i � � i tL .USE ❑ Heating/Cooling <br /> __�_ ___ �_ �_ ��, �Domestic ❑ Monitoring ❑ �ndustry/Commercial <br /> yy i � i , E X ❑ Irrigation ❑ Public ❑ Remedial <br /> _1_ _1_ __ � T ❑ Test Well ❑ Dewatering � <br /> I � �" <br /> �'^"� � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> ' 1'��- �- — —�' �` �Steel ❑ Threaded ❑ Welded <br /> � �m_'�_� j ❑ PlaStiC ❑ <br /> \ <br /> � CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �x� �� �ej �_in.to ��� ft. Ibs./ft. / y in.to � '-ft. <br /> in.to ft. Ibs./ft. '��in.to��i'_-+-ft. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> �CiV .�-OLZ4-ti BTt.3c�CCISN�.V SCREEN��_ OPENHOLE <br /> �ay�"��� [�. �rj,j��{ Make� �� t�7 from tt.to ft. <br /> Type i Diam. %N <br /> SIoVGauze �� Length <br /> Set between 1�$ ft.and Z J% ft. FITTINGS: <br /> HARDNESSOF STATICw���LEVEL 11-1 �-�9" <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ft.�below ❑ above�and surface Date measured <br /> C,��t' � �.,,�„,� ��! �C� PUMPING LEVEL(below land surface) <br /> i .�aiiu v <br /> ft. after hrs.pumping g.p.m. <br /> �I'K� �6�� � 1� C3KPi I ss ad ptOer^manuflaOc urer ��"t���� Myodel <br /> ❑ Casing Protection O"12 in,above grade <br /> GROUTING INFORMATION <br /> Well grouted? �'Yes ❑ No <br /> Grout Material ❑ Neat cement �Bentonite <br /> from to ' tt. � ❑ yds. � bags <br /> from to tt. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST�O�NN SOURCE OF CONTAMINATIO� C�p�/C <br /> S feet �t J V v � � direction �"` -�' type <br /> Well disinfected upon completion? LI'Yes ❑ No l�p�� <br /> PUMP �.., <br /> 3 G-"I�^J J <br /> ❑ Not installed Date installed <br /> Manufacturer's name C� <br /> Model number HP__��olxs a'.J�.1 <br /> Length of drop pipe ft. Capacity. S g.p.m. <br /> Pressure Tank Capacity �-�I2 �V Z�Z <br /> Type: �{Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Z> <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �'No <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> rX::� E��t`�Le'; 6�'�:.�, U�'tI:[:,#:,II�;iC� i.'::�. , :r?+iC:. .:'r'1'i� <br /> Use a second sheet,if needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name Lic.or Reg.No. <br /> �:f���-��" -..�-�.�,�'r 11-17-93 _ <br /> Authonzed Representative Signature Date <br /> I'.P. �zen 11-1i-93 <br /> Name ol Driller Date <br /> � <br /> LOCAL COPY � ��q, 2 6 HE-01205-04(Rev.5/92) <br />