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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> �o«�Y N3�+� WELL RECORD �4 $5 6 2 <br /> �����='1�} Minnesota Statutes Chapter 1031 <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> �T'OYlt) 1�fi �.� i(; '_+ • <br /> c <br /> v. v. �a �.� 1—G�—�_: <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> � ❑ Cable Tool ❑ Driven ❑ Dug <br /> �.3.? ��LL2I�1�: �'c3x1T'i Rt3c�C� C)x'�7I2C%� MTI. J°J �� ❑ Auger �i Rotary ❑ Jetled <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 ' � ��J'�r <br /> __r__�_ _i _1_ ' �S <br /> � , �r� <br /> i � i i ,USE �Domestic ❑ Monitoring � Heating/Cooling <br /> '-a- --- �- �- ❑ Industry/Commercial <br /> yy � ; � E GG! ❑ Irrigation ❑ Public ❑ Remedial <br /> ' T ❑ Test Well ❑ Dewatering <br /> _1_ _1_ __ 1_ I ❑ <br /> � I � <br /> F•m,. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- � C Steel ❑ Threaded ❑ Welded <br /> � �- -r- I ,�wG LL <br /> 1 C�Plastic � <br /> �1 milr� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � �� -� - <br /> in.to �. Ibs./ft. _1- ._a�/(p�..-,(r, <br /> '�111t�iSDI'I�� �VuZC�r� --- in.to_ ft. Ibs./ft. _�'i_lryt4�;,_ft. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. �in.to ft. <br /> F7.j�3 Highpointe Ori��� SCREEN�.����_ OPEN HOLE <br /> 8���+�,�,�+ �`����4��. Make '__����_����� from R.to ft. <br /> I K�l. �LC�ll 11 <br /> Type Diam. <br /> SIoUGauze �`� Length <br /> Set between ��� ft.and �d�. FITTINGS: <br /> HARDNESS OF STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �C� ft. �below ❑ above land surtace Date measured c;—�S— J <br /> ���x � C't t 1(;,PUMPING LEVEL(belo�laafterurface) hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION <br /> r�'s1�IIG ri 1��!� }(�T❑ pitless adapter manufacturer__�1�1 Model <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? J�,Yes ❑ No <br /> Grout Material ❑ Neat cement �Bentonite <br /> from � to ��� ft. -� ❑ yds. ❑Xbags <br /> from to ft. ❑ yds. ❑ bags <br /> from to tt. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF C,OCNTAMINATION � <br /> �U�_� feet t,.. ��_'r,. ! direction ���F�%%C type <br /> Well disinfected upon completion7 C�Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed �-..�,-�[;. <br /> Manufacturer's name <br /> Modelnumber It�+-S �` HP j•�-%Volts 1���' <br /> Length of drop pipe �4 ft. Capacity LU g.p.m. <br /> Pressure Tank Capacity �y���� <br /> Type: L�ubmersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �QVo <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 /> Use a second sheet,if needed �� �,�'t�}}j,�(:i � �,]'�JI�` �j�, I�'� 2"��j� <br /> REMARKS,ELEVATION,SOUI�i�IOF DAT et . Licensee eusiness Name Lic.or Reg.No. <br /> H���� � <br /> i �"_�- 1.—'l.?-9S <br /> ..�.�`"%� � .'; , <br /> � AuthorizedRepresentabve�8ignature� Date <br /> �Yeca �ii�y %--23-9� <br /> Name ol Driller Date <br /> ' ��"'. `'�PY 5 4 8 5 6 2 HE-01205-04(Rev.S/92) <br />