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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
<br /> CountyName WELL RECORD � 5 3 5 6�, 8
<br /> �� Minnesota Statutes Chapter 1031
<br /> i y,
<br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
<br /> � r N � n q
<br /> t v «�.- �� � � �.� ;:� ,.j�� ,. ; , a - �
<br /> Numerical Street Address and City of Well Location or Fire Number DfEILLI G METHOD
<br /> .- t�`, ,� ; ❑ Cable Tool ❑ Driven ❑ Dug
<br /> 1��,.(��; f �v"��i... �.✓ ✓h � �/ . ❑ Auger � Rotary Ll 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 /> 1 i ' � f
<br /> --r---�- -1 -1- � � vl��� i.-ti/ Ca �.
<br /> �
<br /> i � i i � � X ,USE �Domestic ❑ Monitoring � Heating/Cooling
<br /> yy i � i � E ""`"'� ❑ Irrigation ❑ Public ❑ Industry/Commercial
<br /> _1_ _s_ __ __ T ❑ Test Well ❑ Dewatering O Remedial
<br /> � � i
<br /> � f-mi. CASING Drive Shoe? ❑ Yes .Dl No HOLE DIAM.
<br /> --�- �- � -�' I ❑ Steel ❑ Threaded p, ❑ Welded
<br /> � ' 1
<br /> �l Plastic ❑
<br /> �1 mile-� (�
<br /> CASING DIAMETER WEIGHT
<br /> PROPERTY OWNER'S NAME �_ J�(, ? '
<br /> in.to ft. Ibs./R �in.to,}�l ft.
<br /> 1�;''• , <j �1 � . �J , \ u „�^. c, � :�� , �� m.�o n, ibs.in. ���.to�e.
<br /> Mailing address if different tha property address indicated above. in.to ft; Ibs./ft. in.to ft.
<br /> . � SCREEN OPEN HOLE
<br /> S � r
<br /> t �'. � -. ��`�'=+ C: v csi �„ �� L^.�.Y'�(''`� �f S ''- Make •.�r L..n ja v�. from ft.to tt.
<br /> � " Type _" '� Diam.
<br /> � p,, SIoUGauze I ,� Length_; �
<br /> � � �' V T��= `'�'` 1'1"` � � �j i � Set between � 3� ft.and�_��:;_ft. FITTINGS: a X <� !' ';"t�=''t1'
<br /> � � / , �
<br /> HARDNESS OF STATIC WATER LEVEL .
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO "�' � �
<br /> �� ft.�below ❑ above land surface Date measured 1� ` �.,.3'
<br /> PUMPING LEVEL(below land surface) �:
<br /> � �,, ��3 �,��j�, /� � � ) ���d,,� ft. after �. hrs.pumping ��� g.p.m.
<br /> WELL HEAD COMPLETION .( ` , � +
<br /> � �r � � � �l Pitless adapter manufacturer Lr.f`". '�° �/ 4 i eModel ��/Z X ��,�
<br /> �.. { v. ., (�. � _.. .: ,�i f�'t
<br /> ❑ Casing Protection �l 12 in.above grade
<br /> �} � �� r� t p,1 ���,} GAOUTING INFORMATION
<br /> ��. �"� ''a.l`J C� ��.,
<br /> Well grouted? �.Yes ❑ No
<br />�� d Grout Material �J Neat cement � Bentonite �
<br /> from�__to�_ft. � �7 yds. ❑ baqs
<br /> from to ft. ❑ yds. ❑ bags
<br /> from to ft. ❑ yds. ❑ bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> ���feet �j��---� direction ���-s�'�'1 � type
<br /> Well disinfected upon completion? �l Yes ❑ No
<br /> PUMP +�
<br /> R ❑ Not installed Date installed � � " j
<br /> �
<br /> Manufacturer's name 1�1 F ��J".
<br /> Model number HP.� � Vo1lts �.T�-�`
<br /> APR Length of drop pipe '�.,;� ft. Capacity � d, g p m.
<br /> Pressure Tank Capacity ���i X� i��o i
<br /> C Type:.�l 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 �+�� �; '3 `,� �"
<br /> _ �,.= 1 .c.. `�� �.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name Lic.or Reg.No.
<br /> a ��
<br /> � 1 �
<br /> �, � l,�.�Y-w'�-f°'�,... �__;- ��+, _ 1 � ..... ��
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<br /> uthorized Representative Signature Date
<br /> . ,�' l_��i t._:� � _.,�':� '�', !4
<br /> � a�`�� �� , , ... � � � � �
<br /> Name ol Driller Date
<br /> LOCAL COPY � �� � � � HE-01205-04(Rev.5/92) �
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