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... . <br /> WELL LC"AT%rvN��, MINNESOTA DEPARTMENT OF HEALTH <br /> MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD 5 3 6 2 7 3 <br /> ���'��� Minnesota Statutes Chapter f 031 <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> �f7Xtt; ��� i._i �.�;� .���-�i{f��:i�': � ��`Iy� n. _..y?Gjr.��. <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> G�:�i �lA:�,C��'.�,k L1�..S�� ��L�IQ� 0�3.�. ❑ CableTool ❑ Driven ❑ Dug <br /> ❑ Auger �] Rotary ❑ Jetted <br /> Show exact location ot well in section grid with"X". Sketch map of well I�cation. L <br /> N i�howing prope lines, <br /> roads and b 'Idings. DRILLING F�,l�I�D� <br /> I � ' � ,jy C��T1�.C.�1�.'�.�-��. <br /> --r--7- _t _1_ ♦�" ( <br /> � <br /> � � i i _ ,USE � Domestic ❑ Monitoring � Heating/Cooling <br /> ��a- --- �- �- � ❑ Industry/Commercial <br /> yy i ; � , E � ❑ Irrigation ❑ Public <br /> _1_ _�_ _,_ __ �, ❑ Test Well ❑ Dewatering O Remedial <br /> , ; � T � � � <br /> ' r•mc _ _ - '� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- -i- ; -r- I �' ❑ Steel ❑ Threaded ❑ Welded <br /> 1 s <br /> ,4 }Q7 Plastic C <br /> �1 mile-� <br /> � CASWG DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �it E� l /���5' �E5 <br /> `iLT.�'�' VC� �;.t:}1'�t,t`_J.`LI£:�` �n.co .9� n. ibs.in. � �o n. <br /> '�,. �{:� <br /> in.to ft. Ibs./ft. 1 irf?to - ft. <br /> Mailing address if different than property address indicated above. � __ in.to ft. Ibs./ft. in.to ft. <br /> ��� � �(��'�; SCREEN��,"��� �t OPEN HOLE . <br /> �•}y�.��.����' �� -�s�.��� Make '^ C` 1 � � "����"' from ft.to ft. <br /> Type Diam. r� <br /> SIoUGauze Length <br /> Set between ft.and � ft. FITTINGS: <br /> STATIC N(A ER LEVEL <br /> HARDNESS OF !}�j ����'1--�� <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ft�i0 below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> �3=�� � {�'� ���i ft. atter hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION <br /> �'Jc�:�.Y1C�i � ��-�! ���� �Pitless adapter manufacturer �����. Model <br /> ❑ Casing Protection C�:12 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? �] Yes ❑ No <br /> Grout Material ❑ Neat ceme I�Bentgni(e , <br /> > <br /> from � to ''�" ft. t ❑ yds. C�A bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> �"�.:;a feet i.��� direction �:.a�r�.i�.��i.T,►�pe <br /> Well disinfected upon completion? .�I Yes ❑ No <br /> PUMP R <br /> ❑ Not installed Date installed �!�'��* <br /> Manufacturer's name �:clIZ2E:�1C3�� .�,-,�.. <br /> Model number_ HP - Volis � � <br /> Length ot drop pipe �_tft�...��C�a�p�acity � g.p.m. <br /> Pressyure Tank Capacity �1tLt�LC.� �Ic�4..�{ <br /> Type.'"L7 Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ __, <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes I�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. 7 } <br /> WL�C r7�iLK1 TYi:tl.LLa Lfl�i.'R7 ��e� .Lk'0.-. G!�/i <br /> Use a second sheet,if needed ,��,�� <br /> REMARKS,ELEVATION,SOURCE OF��T�etp� n _ Licensee Busmess Name Lic.oi Reg.No. <br /> G L i994 - �-;��--�� <br /> -����-.,���-� <br /> Authorized Representative Signature Date <br /> �"e P• I�lr�=xllC3l� �,_Fl�_,�4 <br /> Name ol Driller� Date <br /> � ��V�� lsQ�� '��" �6� 7 3 HE-01205-04(Rev.5/92) <br />