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<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)
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