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STATF OF�MINNI':5()TA UF'.YANTMF:NT OI-HlALTH <br /> I. L(�l'ATI()N()I�WI�LL F//NNFSOTA UN/QUF WE/.L NO. <br /> ������rN+�� WATER WELL RECORD '� � � ��� :j <br /> � � JorWarcrSample L`-� . <br /> Minnttora SreNfel fShA.lil-.IiX <br /> T�iw�c�ip Name Tnwnship Numher Nan�e Numher S�c�l�n N�. I�ra�'ll�in 3. YRONF;RTY OWNER'S NAMt <br /> N E ; �, y, <br /> m or ., <br /> 1)isi+nce and I)� tliun frum NoaJ Intrrucli��ns��r S�ree1 AJJress anJ('lly o!Well Lnc�iu� Add st������ ��/�� <br /> G <br /> � � ��ii/Yi1A+l _.'"X"!�i'-'.—.—_" <br /> Snnw ea�c1 I��cation o(well in.ec�iun griJ wilh"%." S�e�ch map ot w<Il incation. a.WtLL DEPTH(completed) Date of Completion <br /> N <br /> _L' _ ' _`_'_ " AJJilii�n Name <br /> ft. <br /> .� � � � 5. ,. _ . <br /> i i � r iOc.niri��oi a❑k�.<.x oOn��.�� �oOo�e <br /> e. M -' - _ _ _+_�' _ L bl��ck Numher 2❑HnllnwroJ S�Air B�B�red 11❑ <br /> ' - - '- -� 1S�Rj,. l❑1lF�IatY 6�lelted 9❑►�wet Au`er <br /> _ " ' _ ' � Lol Numl+et 6. USE <br /> � "1_ _ _� " ' '_ __ <br /> i[Yi���m«u< a❑v�n��o s�av�r �O i�a�.vy <br /> $ <br /> �—1�� 301rrie+li��n 5❑MuniciDal <br /> e�C'nmmcrcial <br /> 3. FORMATION LO(: �'OLOIt H�HI)Nh:S50F F'HUM TO <br /> k()NMATIUN l�Trst Well 6❑Air('nn0i�ionin6 9❑ <br /> l.CASING HEIGHT:Above/Below HOLE UTAM <br /> ey)��,�1 �4+_q' � � IDBlack 4❑ThrcadrJ <br /> L iA .i�.46 <br /> iOc.i�N s❑weieed s�rrace tt. <br /> �i�{atis• w,m'�� � �C ��PlastiC ��,� Drive Shoe? Ya_ No ^�_ <br /> �r� ��a f.�.7 (�,, <br /> � in.to �� ff. Weig�t� ��'� Ibf./ft. �7{n.to��. <br /> ��� �����. � �� ' in.lo fl. Weight I�s./fl. —in.to_(t. <br /> . n.lo ft. WeiRh� Ibs./ft. �n.fo_(t. <br /> +�� � � � e.SCRF:lN ��Jy� r open ole <br /> � MakC ����i��/� - (rom f1.io (I. <br /> - TYFe �� Dia. <br /> 1S�"$��� �l�"" �� �� �„'�`{} tJ� <br /> si�yc,�:< ���ern <br /> FITTINGS: <br /> ..���L +��e� Se�belween �� f�.anA �� (�. <br /> � i�"'i7 93 idlG ,. n.a�a n. <br /> 9.STATIC WATER LEVEL <br /> ��� ��� ii.� J..7L �Li n.C'�ri��w ❑�n��< oa��rnee:�.eAL�ii'� <br /> i -- — land wrface <br /> 10.PUMYINGLtVEL(belowlandsur(ace) <br /> � � �� �� (t.afler hrs.0umpin6 iu{/ B.p.m. <br /> f�.a(tet hrs.pumpin6 6.p.m. <br /> 11.WELIHk;AUCOMNLk:TION <br /> �[�'itless edap[er.manutacturer model <br /> z�aa: ����rrsri J�At leest l2"above grade <br /> 12.WELL GROUTED? <br /> lJies ❑No <br /> I�a�C'emi•nl 3�Benl��nile 3❑ <br /> Grout meteriel from to ft..Cu.Yds. � <br /> 13.NEAREST SOURCES OF P06SIBLE CONTAMINATION <br /> �feel direction type <br /> W<II disinfecled upon complef�on? Yes'�' Nn❑ <br /> 14. PUMP <br /> Date instalkA ❑Not installed <br /> Manufac�ureiYName ��� <br /> MoQel Number HP�_Volts z,��, <br /> LengthofdroppiDe ,.,�_ fl.capacitY ��_e.p.m. <br /> Materiei of dro0 p�pe � <br /> Type: I�yuuhmcrsiMr 3�L.S.Tufbine S�Reclprnteling <br /> A <br /> 7❑lel <�C'enlrifugal 6� <br /> Useasecrondsheet,ifneeded �6.WATEHWELLCONTRACTOR'SCERTIFICATION <br /> I5.REMARKS.ELEVATION,SOURCE OF DATA.em. <br /> 'fhis well was drilled unAer my jurisdiction and this repon u true lo <br /> the best of my knowledge and belief. <br /> � icenrer ustniu Namr Llcenx No. <br /> ! � 4�`��`� '� � � „�.�„ fi?�1 H�► � �, �p1e PY,a�a, � <br /> � _ -- <br /> � .. ,.____..�._._—t .�. : <br /> ,,,_,.s.,�,�..>-w - � , t. ,{,� <br /> .. �,.. . � "1 Y Si6n<d ln,.s3-.. .� D�te�� 4 <br /> � . . , . " Aufhorized Represenlaliv< <br /> ��C� �►'�ii@tTtB n.te �"�•-ri—.f��i <br /> e'�di.+-\L COP� ` '� f��� ' NameofDriller <br /> 5/74 30M <br /> ... ' 7/76 30M <br /> -. .� _ .�• ..• 7/78 30M <br /> HEA12o5-Ol 2/82 10M <br />