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� <br /> .,_:�._. ., _. . E " ._. .,_ ._ <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL RECORD �-5 3 7 3 6 2 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> tt. <br /> '/ � i, v. � �� <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> . ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger � Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. O <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> I � ' <br /> --r'--1- -j _1_ . <br /> � � <br /> i � i i ,USE � Domestic ❑ Monitoring ❑ Heating/Cooling <br /> y� -a ; i , E ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> _1_ _�_ __ � T [� Test Well ❑ Dewatering O Remedial <br /> I i ' � - <br /> �'^"� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- �- -, -r- I C Steel ❑ Threaded ❑ Welded <br /> ' ' 1 <br /> �7 Plastic �(C7 (}��� <br /> � /milr� - <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME __�in.to 134 i112 _ Ibs./ft �I��o��� n. <br /> ;� in.to ft. Ibs./ft. in.to ft. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make J�yC� from ft.to ft. <br /> Type �� p Diam. <br />�,. SIoVGauze li7 � Length <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR H MA�EERIAL�� FROM TO !�y ft. f�below ❑ above land surface Date measured-��F;--i f��' <br /> PUMPING LEVEL(below land surface) <br /> ���CI, /� � ft. after 3�¢ hrs.pumping � g.p.m. <br /> R V <br /> WELL HEAD COMPLETION <br /> G�a � C.,,�d Y���Q� ❑ Pitless adapter manufacturer Model <br /> sci <br /> ❑ Casing Protection O 72 in.above grade <br /> Cla & Sand B� � GROUTINGINFORMATION <br /> � Well grouted? ❑ Yes ❑ No <br /> � Grout Material ❑ Neat cement ❑ Bentonite <br /> ��a from to ft. ❑ yds. � bags <br /> from to tt. ❑ yds. ❑ bags <br /> � & from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION � <br /> " feet direction type <br /> • II disinfected upon completion? ❑ Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed <br /> Manufacturer's name �f„�, <br /> Model number HP� Volrts <br /> Length of drop pipe ft. Capacity �J g.p.m. <br /> Pressure Tank Capacity <br /> / Type: � Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> � . -- -''--" � i '' Does property have any not in use and not sealed well(s)? Yes ❑ No � <br /> ..._. ..- 1�"...., ... <br /> ! <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,il needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. ����4 <br /> icensee Busn ss m ' '� � . Reg, ��� <br /> M�R 7 YS ��� � "��Z�28/84 <br /> ,.- - Authorized Representative Signature Date <br /> Michael Stevens 2/28�94 <br /> Name ol Oriller Date <br /> LQt:AL C��'`l 5 3 7 3 6 2 HE_o,zo5_o4,Re�.5,�2> <br />