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C � �a' <br /> MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> WELL RECORD 5 4 8 4 6 9 <br /> �, Minnesota Statutes Chapter 1031 <br /> �'i..lf?''s�i <br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> 118 23 36 ,. ,. ,. 146 8-9-94 � <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger p,}iotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ �� <br /> Showing property lines, <br /> ry roads and buildings. DRILLING FLUID x <br /> I � ' � <br /> '_r'_y_ _1 _1_ n..�.�.�....t}e <br /> � � KiILVLil V <br /> i � � i � ,USE ❑ Heating/Cooling <br /> __+_ ___ �_ �_ ❑ Domestic ❑ Monitoring <br /> � ❑ Industry/Commercial <br /> W � � � � E �� �Irriqation ❑ Public ❑ Remedial <br /> ' T C; Test Well ❑ Dewatering � <br /> _1_ _1_ _'_ _' I � <br /> I ; � <br /> F"m'. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --�- � � ' 1 <br /> � �- — —r- ❑ Steel ❑ Threaded ❑ Welded <br /> � ;/� a Plastic ❑ � <br /> � I mile—� (1 (,� .7[ �� <br /> �� � �. <br /> G✓Uv y CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 1�� __(�__in.to_��,�__ft. Ibs./ft. ����_'� <br /> in.to fl. Ibs./ft. � '(i,JA 1 l.t <br /> �a-i.��-f��►V <br /> Mailing address if different than property address indicated above. in.to tt. Ibs./tt. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make �'1'�[� �!!� j'] from ft.to fl. - <br /> Type_Ld'i-������_C�,`�r�fQ�Diam. ` <br /> SIOUGauze Length ).f <br /> Set between '�(�,�_ft.and_ 1/�ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO � ft.�below ❑ above land surface Date measured <br /> MATERIAL <br /> �+�� p� PUMPING LEVEL(below land surface) <br /> a721[Ri�C�y .S'�ft � CXJ ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION <br /> Ci� $�ft £� 235 � Pitless adapter manufacWrer Model <br /> ❑ Casing Protection 12 in.above grade <br /> ..'733[AL SfOC 13� �"#� GROUTING INFORMATION <br /> Well grauted? ❑ Yes ❑ No <br /> Grout Material �Neat cement L1 Bentonite <br /> from____���to�__ft. �_ ❑ yds. � bags <br /> from to fl. ❑ yds. ❑ bags <br /> from to tt. ❑ yds. ❑ bags <br /> NEARE1ST KNOWN SOURCE OF CONTAMINATION <br /> 1����_feet �,�r�C� direction �EC.uL��� rype <br /> Well disinfected upon completion? �Yes ❑ No s <br /> PUMP <br /> ❑ Not installed Date installed ���(� <br /> Manufacturer's name � ,��+�j-�� <br /> Model number - HP�__ Volts ��� <br /> Length of drop pipe ot ft. Capacity �� g.p.m. <br /> Pressure Tank Capacity A7/A � <br /> Type: C3x6ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? �J 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 irue to the best of my knowledge. - <br /> Use a second sheet,i/needed �� '4v,"t��l� �,�� ��1i� (�„ � Ij�� 2T1'Hf <br /> c�ti__ J 1/L <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. <br /> f � , <br /> � <br /> � __ - <br /> S E P .. �s'=��'`�.,-=�. --- .� ; ��- �-2r�L <br /> 2 � �������� Authorized Representahve Signature Date <br /> P.P. Mct�� 8�-+�-9L► <br /> Name ol Driller Date � i <br /> �.oc�,�. co�Y 5 4 8 4 6 9 HE-01205-04(Rev.S/92) <br /> � <br />