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-��■.� <br /> WELL LOCATION � MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNlQUE WELL NO. <br /> CounryName WELL RECORD 5 61 ��1 <br /> ��'-�'�=i'�'' Minnesota Statutes Chapfer 7031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> tt. <br /> ( C�f'ii.i �( i r� t�J `,�v e'L--��I. C�t i. !,;(; ry; c"- <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br />� �� • -- ❑ Cable Tool ❑ Driven ❑ Dug ��.. <br /> � �'Sl' � . t� .:slt �r,: t�s�.E'. �.�"C�11�' �'.�:. . C <br /> ��7 ��-' ��' ❑ Auger ❑ Rotary ❑ Jetted �i <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 � � � �[ � <br /> --r---Y -1 -1- ' ..`� + . .�! �� ---- <br /> i � i � ♦ y .USE ❑ Heating/Cooling <br /> __+_ ___ �_ �_ 3 f� [] Domestic ❑ Mo�itoring <br /> W � � E �] Irrigation ❑ Public ❑ Industry/Commercial <br /> _1_ _i_ __ __ T 4 ❑Test Well ❑ Dewatering O Remedial <br /> I • i � � � <br /> f-mi. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --;- ;- ' -�'- j = ❑ Steel ❑ Threaded ❑ Welded <br /> �--_- � � Plastic ❑ <br /> � I milr� <br /> CASING DIAMETER WEIGHT <br /> PFi'4PERTY OWNER'S NAME in.to ��! � ft. �tnh2-i� Ibs./ft. �y�„� �-�h. � <br /> ,s'; ± 1.iLiI.;2 in.ta tt. Ibs./ft. i .eW R <br /> �-�f -��-i <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. in.to_ft. <br /> SCREEN U-,'1 i i-,,,-.»�.-a� OPEN HOLE <br /> Make � � l from ft.to ft. <br /> .C�'�L <br /> TyPe ._.....� i_ ..:., .. Diam. <br /> SIoUGauze - Length �A <br />"� Set belween �E%,'. tt.and �f�k; ft. FITTINGS: f <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO i���i �� . <br /> MATERIAL ft. C�below ❑ above land surface Date measured T t:--::�-,,_. <br /> r <br /> 1 PUMPING LEVEL(below land surface) <br /> � ��� � 1`:�� ft. atter <br /> i.1��.���' �i��:Ii .. t: �.,;. �='.` hrs.pumping �_i. 9.p.m. <br /> WELL HEAD COMPLETION <br /> {,..�.'�j ti1:E'1� :� °+� �l` ° �-;Pitlessadaptermanufacturer �`J�ll#'E'F�;�3'f`f-�? Model ' <br /> ❑ Casing Protection �1 12 in.above grade <br /> C.�;``T-(.it.,"-�."f`.'�.. GL`��� I�i C;`._�� S��'� i GROUTINGINFORMATION - <br /> Well grouted? ;{1 Yes ❑ No <br /> � , C'. I� Grout Material ❑ Neat cement �,Bentonite <br /> . . ii(:� '1:��.';1:. .. �:,, �f:�i:. <br /> from to ' R �� O yds.;�l bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWy$OURCE OF CONTAMIN�TION � <br /> ��;`'�_feet ���direction �! > � tyPe <br /> Well disinfected upon completion? Q Yes ❑ No �� ti,.. � ',! �. <br /> PUMP � <br /> ❑ Not inslalled Date installed � - � <br /> Manufacturer's narqe � � �i . -- <br /> Modet number � - ���`' '�`'-�� �HP ���i��" Volts <br /> �ength of drop pipe t ft. Capacity g.p.m. <br /> Pressure Tank Capacity •���: , �,: j <br /> Type: O'Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes !.l.�;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 /> �� <:-�i �r - ' 7'� I)11��..�sLa�!�'�: �..:.. .� �.Td�.. �.. i l / <br /> ....� .1.�.il�%1 YI�: 1`^�.l:.E��.! r <br /> Use a second sheet il needed <br /> REMARKS,ELEVATION,SOUR�E OF DATA,eta LicenseeBusinessName lic.orReg.No.. <br /> ��� .. <br /> /-''' � '� '�`' -���-` <br /> � 5 p � <br /> Authonzetl Representative Signature Dafe <br /> ;'Y:-''C: .�F'_:i�3�r �ii-�--�':: <br /> i <br /> Name o/Driller Date <br /> LOCAL COPY 5 614 O 1 HE-01205-04(Rev.5/92) <br />