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h'� � STATE OF MINNESOTA DEPARTMENT OF HEALTN T <br />�3 t.LocnT�orr oF we�t WATER WELL RECORD ,titin�NFso�a uH�eur�wF�t.c No. A����� � <br /> County Name `� <br />� u�� iNinnesota Statules 156AAL-.OH for Wa(rr Samp(e <br /> i1�iII� 1� <br /> Township Name Township Number Range Number Section No. Fraction �1.WELL UEPTH(compleled) Uate of Completion <br /> � �'�I`�=�1'4�'t 117 'N r:3 y� ;:! R'�,: t�r. :�k; v� jr�3y (�. �^-'i2�7i <br /> Numerical Street Address and Ciry of Well Location or Distance from Road Intersection. 5. DRILLING METHOD <br /> 1!jii �.,C.�i.�+;:. �+.��LCi. P�i>���l�L`�� � 1,.��(.7� M3..�' . ❑Cable'lool ❑Reverse ❑Dr�QF <br /> lJl�� <br />' Show exact loca[ion of well in section grid with"X." Sketch map o(w�ell location. �H�11O`9�`� �A'� //�� <br /> - N ..�, �� A��'n� <br /> � i i Addition Name �_! � C�2otary ❑Jetted ❑Pou K r <br />�yhe`: --r--'�- -1 -1- lti;�' 6.DRILLING FLUID <br /> i ' i i <br /> __1_ ___ _ �_ BlockNumber . <br /> W i I E 7. USE �1 <br /> � .��;., �y'Domestic ❑M�tbri� r ❑Heat Pump <br /> I �1 i � � Lot Number "� � .• ❑lrrigation ❑Public � J O Industry <br /> ' '/_-mi. , � � <br /> � \ ,/� O Test Well ❑Municipal O Commercial <br /> --�- �- ; -r- I �'� 'Y, ,�'Jl ❑Air Conditioning O <br /> � i r! <br /> �—1 milr—� � � ���� ���' 8.CASING HOLE UTAM. <br /> 2.PROPERTY OWNER'S NAME Mailin�Address if different[han property address �g�ack HEIGH7':Above/Below <br /> �Threaded <br /> ��� � �.,,���.� ��� indica[ed above. Sur(ace (t. <br /> ❑Galv. ❑Welded <br /> <<;��,� �"����j �1,�? Drive Shce? Yes r' No— <br /> � ❑Nlastic ❑ l� <br /> ;J''.,,, p,�� � ti <br /> �i �� �,; �� �� <br />�. 7 �'iJW�� iur�� -�� .{) � ia to�tL Weight��-IbsJft. '-r n. to �t. <br /> 3. FORMATION L(� COLOR HARDNESS OF p'NOM TO in.to (t. Weight IbsJtt. ��n. ro=�olt. <br /> FOKMATION <br /> in.to (L Weight IbsJft. �n. to—Jt. <br /> . ._� 9.SCREEN Or opea,,h�q�l� .. .�,� <br /> (rum�tt.to ��}t' ft. <br /> Make <br />�.a,��- �'y,� Diam. <br /> ,^ <br /> SIoVGauze Length FITT[NGS ��� <br />� s <br />,p,': .-�f Sel between (t.and (t. <br />��� 10. STATIC WA'1'ER LEVEL <br /> . f... .� `�t-f- '7C, � �t% (t.�bclow ❑abuve Date Measured L������ <br /> land sur(are <br />;�� I1. PUMPING LEVEL(below land surface) <br />�,' �� �E (t.atter '� hrs.pumping 1�.� g.p.m. j� <br />�', `< <br /> ft.after hrs.pumpmg g.p.m. <br />� ._; I'L.yHEAD WELL COMPLETION ""` <br />�,�^. 16�Pitless adapter manufacturer�17�.P �lt�' M�uiel <br />�.-�. '.O Bas-ement,o(fset �"At least 1'2"aboce ground <br /> ❑Plastic casfng protecuon �'� <br /> e;;:`,:: <br /> i^�+': <br /> ty�, 13.WELLGROL'TEU? .�'l' Yes ❑No :x;+ <br /> .�� �`�g' '[i�i: t?Y..y^� m <br /> � ❑Nea�Cement ❑Bentonite ���C'�'L I � � <br /> Grout material from to (l.cu.yds. _ ..� <br /> r <br /> � <br /> � ; ; <br /> 14. NF:AREST SOURCES OF POSSIBLE CONTAM[NATION �� <br /> � <br /> - (eet direction type <br /> � Well disin(ected upon complrtion? d3Yes ❑No <br /> lo. NUMN <br /> Uate installed �^}-�-'��� ❑Not installed �:�� <br /> Manufacturer's name �E^�-� i <br /> Model number y HP�i.�Volts�'� � <br /> I.ength of drop pipe +«-��� ft. C apacity [� 8 P.m. '�= <br /> Material of drop pipe ��� ��'� ��'? <br /> Type: �ubmersible ❑L.S.Turbine O Heciprocating 'k„'� <br /> `� <br /> ❑Jet ❑Centrifagal �O <br /> z_;;� <br /> 16. AI3ANDONED WELLS -��� <br /> Unused well on property? ❑Yes �No <br /> Use a serond sheef,iJ needed Sealed ❑ Permanent ❑ Temporary ❑ No�sraled <br /> 17.REMAHKS,ELEVATION,SOURCE OF DATA,etc. <br /> • I8.WATER WELL CONTRACTOR CERTffICAT10N <br /> This well was drilled under my jurisdiction and lhis report is true to the best o(my <br /> knowledge and belief. <br /> � il�/lA/1J1�1 �11'1".af.i�-� 1.�1r:•�1'N Lhf.� 11.Y1..r �-��/L <br /> Lirensee Business Name Lirense No. <br /> Address 1.�3{)Ei Hzc;I1�'��y �s ?'r �,�:.t� I�3t'1. =i�3�5 <br /> s+g��""' � "'�.,s,__�-+„ - '�.� Date 2=11-91 <br /> .�t.�L, Authorized Ftepresen(atioe <br /> �`�. �, ��1(�7'�'i�.i",'!'j Date i''"'��-"��� <br /> Name ojDriller <br /> C �-} 5/74 30M <br /> LOCAL COPY � � J� lJ � '�'s 3°"' <br /> 7/78 30M <br /> HE-01205-03(Rev.9/88) 2/82 tOM <br />