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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
<br /> CounryName WELL RECORD 5 2217 2
<br /> �t f ,L,:r „;i ,,y; Minnesota Statutes Chapter f031
<br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
<br /> c� n �
<br /> � `��;�rv� l�� j .I �S ��,� �. �" �. U�] / ' �
<br /> Numerical Street Address and Ciry of Well Location or ire Number DRILLING METHOD
<br /> � . ❑ Cable Tool ❑ Driven ❑ Dug
<br /> � !' ` '� ! a- � -% i: !'' "� ❑ 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 ��f roads and buildings. DRILLING FLUID
<br /> I � � � '.} .-., ...�-r^--. ...
<br /> --r'—'1— —1 —1— i (� �'�" i_._ - .,r
<br /> l�
<br /> i � i ,USE ❑ Heating/Cooling
<br /> � � �Domestic ❑ Monitoring
<br /> --+- -',- �- �- ❑ Industry/Commercial
<br /> yy � , � � E i/t t� 4/ ❑ Irrigation ❑ Public
<br /> _1_ _s_ __ __ T ❑ Test Well ❑ Dewatering � Remedial
<br /> � � � �
<br /> ' h m;. CASING Drive Shoe? ❑ Ves ❑ No HOLE DIAM.
<br /> --�- �- ; -r- I ❑ Steel ❑ Threaded ❑ Welded
<br /> � 1 �Plastic ❑
<br /> �1 milr—� �,5 l ✓
<br /> n/-"S3 jw. �
<br /> CASING DIAMETER WEIGHT
<br /> PROPERTY OWNER'S NAME � in.to J u�tt. ,,r� �' `? Ibs./ft. �in.to-��L�ftT.
<br /> ,_i �: �r , � i l'- r .:� yv, in.to ft. Ibs./ft. !�'n.to�
<br /> Mailing address if different than propeRy address indicated above. in.to ft. Ibs./ft. in.to ft.
<br /> ! � G �,f� ,� (,(� jf.�/ ��� , SCREEN OPEN HOLE
<br /> • � .` Make � �' �� from ft.to ft.
<br /> r / .�
<br /> vb'`I r.�4� li-� !� f �"�� /C'� �+ �- f/ .)� �'�.. TYPe -� G. Diam.
<br /> SIoUGauze �,f'� Length .� `
<br /> Setbetween ���,2 tt.and�__�_'�ft. FITTINGS:�.�v��j_T_�����=
<br /> STATIC WATER LEVEL
<br /> GEOLOGICAL MATERIALS COLOR H MATERIAL�F FROM TO ft.�below O above land surface Date measured
<br /> r,rj �j� � PUMPING LEVEL(below land suAace)
<br /> j „ �, Y� ! ��,�,.��_� � ,�� � t) ft. after � hrs.pumping ,,�� g.p.m.
<br /> �
<br /> WELL HEAD COMPLETION e .{� �G �
<br /> � f/`l:^ J: � � �'( ,; f . , �"� �,� C�Pitless adapter manufacturerLY+s*�..L.. _���iw...-- Model .3-� f ���
<br /> ,r'�
<br /> _ ❑ Casing Protection ❑ 12 in.above grade
<br /> r� � /"�' � � �(j�� � GROUTING INFORMATION
<br /> ,
<br /> .._._:...,/_-'-�, _ , T �.,.tli"+.fi
<br /> Well grouted? f�Yes ❑ No
<br /> � �� � { � Grout Material t�Neat cement ❑ Bentonite
<br /> , %��..- �r�.�
<br /> from .T/1 to��ft. ❑ yds. ❑ bags
<br /> t- � � � from to fl. ❑ yds. ❑ bags
<br /> �i • J
<br /> � 4,�, �y/� �-`„� '/ ! � �� from to ft. ❑ yds. ❑ bags
<br /> ��,,J� � ..
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION r�;
<br /> � ✓ r�✓,� �� s . �t"'J `� _�_3 teet r5.i directior�.-�type
<br /> ,-.
<br /> �- ;/ Well disinfected upon completion? �Yes ❑ No
<br /> PUMP
<br /> �Not installed Date installed ,,y,_
<br /> Manufacturer's name ��./�-s-�•-�-•"�''/
<br /> Model number �T! �� HP_��_ Volts..� � (j
<br /> Length of drop pipe ft. Capaciry ��j g.p.m.
<br /> Pressuie Tank Capacity � � ,�,,.
<br /> Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
<br /> ABANDONED WELLS
<br /> Does property have any hot 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�rue to the best of my knowledge.
<br /> Use a second sheet if needed �� ���. � � ��e 1���('-.��,•� ��/ �) /
<br /> �7 C s / �{.a
<br /> REMARKS,ELEVATION,SOURCE OF DATA,eta Licensee Business Name/^� Lic.orReg.No.
<br /> � �'..:� � ���� e�. > � ��
<br /> Authorized Representative Signafure Date
<br /> L t�('fJ�. ?
<br /> r�p}� / � ' � J
<br /> C! �'�1 -f,�jr^ �c''��?vLu-,_. �` ,
<br /> Name ol Driller Date
<br /> LOCAL COPY 5 2 217 2 HE-01205-04(Rev.S/92)
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