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�OFLL LC�ATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL RECORD ,� <br /> � � �� � � <br /> �''<'r'S�P'">Z-== Minnesota Statutes Chapter 1031 `�-% ��+ �� <br /> Township Name Township No. � Range No. Sectioh No. Fraction WELL DEPTH(completed) Date Work Completed <br /> C.-��'I11�. I ? , ..� , �. '� �� � a. 3�_� .��� <br /> � ;. <br /> v. v, v. <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> .- 1�fC1]'�i:.�s, .f�..i:;.' i3;Y'i�.''E'' (.'�ti`Tll!� T'�'s.. G CableTool ❑ Driven ❑ Dug <br /> ❑ Auger .O Rotary �] Jetted <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 � ' ' <br /> --r--7- -1 -1- � � � '�:� <br /> i �--- <br /> i ' � .USE ❑ Heating/Cooling <br /> ._i_ ___ �_ �_ 0-Domestic � Monitoring <br /> yy i ; i E ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> _1_ _s_ __ __ T ❑ Test Well ❑ Dewatering O Remedial <br /> I , � ' <br /> � , / <br /> �""° CASING Drive Shoe? Cj�Yes ❑ No HOLE DIAM. <br /> --�- �- ; —r- I � ,��('. O•�Steel ❑ Threaded ❑ Welded <br /> t 1 ❑ Plastic ❑ <br /> �—I milr� <br /> /y /C�f"t /•T Ic I`J�°� ��I. CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �f'�- � '•�`��% <br /> .. .1:i .�.�r�.,t ..:P::�: in.to ft. Ibs./ft. in.to�tt. <br /> in.to ft. IbsJft. �in.ta -� ft. <br /> Mailing address if ditterent than property address indicated above. in.to R. Ibs./ft. in.to ft. <br /> SCREEN�„Y,� OPEN HOLE <br /> � <br /> Make � from ft.to ft. <br /> TyPe .. `Y l r#� �?5� :.il:�_'..'.� Diam. � <br /> SIoUGauze ��' Length <br /> Set between �:'i= ft.and_ir+x__tt. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO ft. E'�be�ow ❑ above land surface Date measured { �"�� "'�' ` <br /> MATERIAL <br /> PUMPING LEVEL(below land surface) <br /> t��' ' ' � �: ' ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION <br /> t`;�'?1 °L;�iL:_.Y <br /> :•�,�,G;;i ���'..��" }�i 'O;�itless adapter manufacturer Model <br /> ❑ Casing Protection E? 12 in.above grade <br /> GROUTING INFORMATION <br /> Well grauted? d Yes ❑ No <br /> Grout Material ❑ Neat cement ❑ Bentonite <br /> from to ft. ❑ yds. Q bags <br />� from to fl. ❑ yds. ❑ bags <br /> from to R. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> teet direction rype <br /> Well disinfected upon completion? ��.Yes ❑ No <br /> PUMP <br /> 11--�1 . �t� <br /> ❑ Not installed Dat��i.rfqt�M�[�_; <br /> 9 A Manufacturer's name <br /> `t Model number . ..,� HP_�Yolts G��- <br /> NO Length of drop pipe + ft. Capacity ``' g.p.m. <br /> 0 Pressure Tank Capacity 4i+'1�- �`"i��-'-t x''+-�-� <br /> CType:.[] Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes O'�No <br /> WELL CONTRACTOR CERTIFICATION <br /> This weli 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 /> _. , ` �.� �1 ..:i '. ::i 1 ,_.�. `, .., , �[�� . f'i:_ <br /> Use a second sheef,il needed <br /> REMARKS,ELEVATION,SOURCE OF DATA,eta Licenseeeusin ssName � '�Lic.orReg.No. <br /> -..�--� __�... � � �--���--i��, <br /> _ �� . �_ <br /> Aut oriz RepresentativeSignature ���� Date ; <br /> _ 3'� - l 7��_:�4'C: �Z._� (;"< <br /> Name ol Oriller Date <br /> LOC�,L CO�Y 5 3 � �n 7 HE-01205-04(Rev.5/92) <br /> V <br />