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�a- <br /> . <br /> .:..__ ..... ,.; .:.... . . .�,.. . _..� . . _-.,....�. _ . . . � .. � <br /> ..' . . . . . . . .: ... ._ .. � ,..„.,,.. . ... � �< _. . . . . � � .',,r_. <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. <br /> CountyName WELL RECORD <br /> Minnesota Statutes Chapter 1031 5 3 Q 15 6 <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ,,;. �.,.: ..3,- / � ,� ,� 3 ' ` s h..,,.��,. .��, ,. � o h 7 J -r�' .J' <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> � - � . --�� ❑ Cable Tool ❑ Driven ❑ Du <br /> r � `� -' f G:i., (.^ i �.;�'�' � !' '� tr ❑ Auger �Rotary ❑ Jett d <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 � � I"'`` . . <br /> --r--7- -� -1- - i�`-� .:.<' '_ - <br /> i � i i . � ,USE �Domestic 0�Monitoring � Heating/Cooling <br /> '-�" --- - �- ❑ Industry/Commercial <br /> W � i � � E ❑ Irrigation ❑ Public <br /> _1_ _;_ __ __ T r c� �� ❑ Test Well ❑ Dewatering U Remedial <br /> � ' i � � � <br /> � ��"'"'� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> ' 1'-�- �- — —�' ��._,�,_„�_.,�^—'"' ❑ Steei ❑ Threaded ❑ Welded <br /> ,�lastic ❑ <br /> �I mile� <br /> { <br /> �``�� `������� CASING DIAMETER WEIGHT <br /> PROPERTY O�ER'S NAME �in.to /� � n. ..� �/ J Ibs./n. � ;n.to .t'vn. , <br /> : E. ;_:�.� in.to ft. Ibs./ft. e" i%�n.to��ft. <br /> Mailing address if different thanpjp{ierty address in � �ted above. _ in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE � <br /> Make ,,� %� C � from tt.to ft. <br /> . Type /��L�-- Diam. � <br /> SIoUGauze J a Length <br /> Set between � (J J ft.and �u ft. FITTINGS: �/`� r-.. <br /> HARDNESS OF STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 7 (� tt.�below ❑ above land surface Date measured � -•% � � <br /> . -� ..., PUMPING LEVEL(below land surface) <br /> /.. ��-�.` : /��fj � _ ( <br /> ' J�. -- � �..J/ N�'�v-- �j'L�W� �.� ,J� � U fl. atter ,t hrs.pumping �� t7 g.p.m. <br /> � WEIL HEAD COMPLETION <br /> i% <br /> ��F� ,�'(.� � /_� �f/� �� � � �.Pitless adapter manufacturer �^-�-���-��-- Model -> � ;I <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> 4 i <br /> � � � J <br /> ,,.�" � •. �'=ri,-_;�� �..r �r r„_,.� S i!_'� GROUTING WFORMATION <br /> - Well grouted? [9�Ves ❑ No <br /> Grout Material ,�'Neat cement ❑ Bentonite <br /> from_ �to � fL + ❑ yds. 69� bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION - <br /> , ;;�w. _�%�,r/ type <br />- �� -�� feet /� � direction <br /> Well disinfected upon completion? ❑ Yes ❑ No ,{i ���_y/ <br /> PUMP <br /> ❑ Not installed Date installed 1 ,S�� � f x <br /> Manufacturer's name r-C.��r"x-z _-��-��„�. .. <br /> Model number .� J� a n7 HP ��� Volts / � J� <br /> F <br /> Length of drop pipe ,J' � ft. Capacity � � g.p.m. <br /> Pressure Tank Capacity ,1 � �� <br /> Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes �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 /> Use a second sheet,if needed �� � � " �� �� �' � <br /> �-- C ..1 �.ti ..��� =� -;= �s / ✓ l � S <br /> FIEMARKS,ELEVATION,SOURCE OF DATA,eta Licensee Business Name Lic.orReg.No. <br /> �.,'� ,. -- ���` � -'` ,� s� f <br /> Authorized Representative Signature Date �i <br /> ' ' / _. <br /> ,� i <br /> r- . ��_ E_. �- ���..-s__�_.��,. _ � .d � <br /> U <br /> Name ol Oriller Date <br /> LOCAL G��PY � 3 0 :� � 6 HE-01205-04(Rev.5/92) <br />