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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name ) f WELL RECORD �- ,.� � ,a 4 � <br /> T"t t'tn � Minnesota Statutes Chapter 1031 `--� �- �- <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(oompl�ted) Date Wock Completed <br /> �`` .c ��:. M i`� "f �-�w � ���. �a. fW,,. ��� tt a. — `� � <br /> Numerical Street Address and City of Well Location . or Fire Number DRILLING METHOD <br /> - 1'�J �i.;� (. � " l �� V �� ❑ Cable Tool ❑ Driven ❑ Dug <br /> �f ' �- S � ❑ Auger [T.Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> ry roads and buildings. DRILLING FLUID <br /> I � � <br /> _i _i_ �,t. l.� � 1 e; �. <br /> --r---7— i � � ��..� <br /> i � � i �� ,USE �mestic ❑ Monitoring '� Heating/Cooling <br /> `t- ❑ Industry/Commercial <br /> �y �' � i � E {� -" ❑ Irrigation ❑ Public ❑ Remedial <br /> _1_ _�_ _,_ __ T 2, � { ���, ❑ Test Well ❑ Dewatering � <br /> � � � � .�, l„r,_.---� __.i <br />,,.. 2�mi. '+� ` CASING Drive Shoe? ❑ Yes �No HOLE DIAM. <br /> , 1 f �„ <br /> --;— i— — —r- , i^ �` � ❑ Steel ❑ Threaded ❑ Welded <br /> ''-� �Rlastic ❑ <br /> �1 mile� <br /> � CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �j !t{t� <br /> l in.to fl. Ibs./ft. �in.to .3�.ft. <br /> i � .✓�. �••! �; ., '. t/�'r�. `� t,. in.to�* ft. Ibs./ft. �in.to� <br /> W n. <br /> Mailing address if different than property address indicated above. in.to T ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> �. - � Make �(;y�l� •� �� �" from .to�_ft. <br /> •"�� 4 ��_ � . <br /> _ Type "i Diam. a <br /> SIoUGauze 1 � Length t�� <br /> Setbetween � �"+L'� ft.and 1����� ft. FITTINGS: ��7`��i �� <br /> HARDNESS OF STATIC WATER LEVEL _ <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ;�'� ft.�be�ow ❑ above land surface Date measured � `" E .� <br /> PUMPING LEVEL(below land surface) <br /> �_. '���) ��l�' V\ �/`^.. �.� � ` � i.'�' ft. after a.. hrs.pumping ��_g.p.m. <br /> WELL HEAD COMPLETION �1 '� / <br /> �� t ��- � ,��„� � � t � �,/ ❑ Pitless adapter manufacturer �'��^��� ���`�%�"�4 Model E"� " 'j � r��:� _ <br /> n- <br /> ❑ Casing Protection �9„12 in.above grade <br /> �„f•�,.,�� z�� r �",v�� � c_..,� ,� �f �l�j GROUTING INFORMATION <br /> � CJ �;' . <br /> Well grouted? �Yes ❑ No <br /> Grout Material �Neat cement �+Bentonite �_. <br /> from�`to ft. + � yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> � NEAREST KNOWN SOURCE OF CONTAMINATION <br /> _-�' feet �—' direction � L' rype <br /> Well disinfected upon completion? �Yes ❑ No j -� '�'�*� <br /> PUMP \ G <br /> + ❑ Not installed Date installed K — i-� <br /> V F Manufacturer's name �`��c ' !"f G <br />� ` i � <br /> Model number HP � �- Volts ✓ ��� <br />� 2 2 199 Length of drop pipe �%� ft Capacity ; �. g.p.m. <br /> Pressure Tank Capacity ���� �- �` f 1 i� i, <br /> O O Type: f�ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> OF �R <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �,No <br />� WE�L 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 ihe best of my knowledge. <br /> t f Ci <br /> Use a second sheet,il needed ����+� . �+!` i._: � . „�„- .� <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name Lic.or Reg.No. <br /> �r <br /> �-�', -+._ ��1. ,.:�-- � - ,� � <br /> 1 � � Authori d Representative Signature Date <br /> _ ��r_;�c_.,- �.. . <br /> �t <br /> �_ _ 1z �, ,� E�w��, a - � <br /> Name of Driller Date <br /> LOCAL COPY 5 2 5 2 4 � HE-01205-04(Rev.S/92) <br />