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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.�
<br /> CountyName WELL RECORD � .�������'�....�.
<br /> �{r �-�f� � � Minnesota Statutes Chapter 1031
<br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed �
<br /> tt
<br /> ' Y�'�r i'7i r� 1 � .? ,3 �� �. '�.,�. / f/ ,�!'�'" j 'L.
<br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
<br /> -)�, ❑ Cable Tool ❑ Driven ❑ Dug
<br /> � ' ❑ Auger �,,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' y_ _1 —L_ . i� �..
<br /> � � �' �� . _ '.r
<br /> _a_ ___ i_ �_ J ' ,USE Domestic '� ❑ Monitoring � Heating/Cooling
<br /> W � � � E O Irrigation ❑ Public ❑ Industry/Commercial
<br /> � T � ❑ Test Well ❑ Dewatering a Remedial ! '
<br /> _1_ _1� _'_ 1' I
<br /> I n; j �
<br /> 2-mi. E �'� " r�'�,. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
<br /> --�- �- � -r- � ❑ Steel ❑ Threaded ❑ Welded
<br /> 1 i�+.- �7 -_.. .
<br /> Plastic ❑ _
<br /> �—I milr'—� :w�.-. r" ~
<br /> CASING DIAMETER WEIGHT
<br /> PROPERTY OWNER'S NAME _�__in.to���ft. } �1 Ibs./ft.
<br /> e. �in.to.�j�tt.
<br /> .".. in.to ft. Ibs./tt. �_�.to�'�ft.
<br /> � in.to ft. Ibs./ft.
<br />,� Mailing addres if different than pro erty address indicated above. in.to_ft.
<br />. SCREEN OPEN HOLE
<br />'� Make � �C.�r from ft.to ft.
<br /> Type_t,'"� Diam. Y
<br /> SbUGauze � �;t'" Length �
<br /> Setbelween ! ;�s � ft.and�`�'�_R. FITTINGS: k' �"'�-�_�.. �
<br /> HARDNESS OF STATIC WATER LEVEL
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ,7' '� ft.gbelow ❑ above land surface Date measured ��- J✓ f�
<br /> �1
<br /> �� ,r- PUMPING LEVEL(below land surface) . �:�
<br /> f..v,`•2,�,,,� �^,r;E,pQ � � ?�"� ft. after ,g hrs.pumping .f � g.p,rn,
<br /> � �
<br /> s r � WELL HEAD COMPLETION
<br /> t f� ��„�.� � . � (� ['�{ (�Pitless adapter manufacturer tn....�.�..:+!!"L Model � �' _�
<br /> ,/ �j ❑ Casing Protection ❑ 12 in.above grade
<br /> �� /' �� ' S I Q GROUTING INFORMATION
<br /> ... - - r�++'-eN.
<br /> -r-' Well grouted? �7,Yes ❑ No
<br /> r...� .,e�
<br /> C' f/ � � Grout Material �,Neat cement ❑ Bentonite
<br /> ������ ¢�`�� � �� from�to��ft. ❑ yds. ❑ bags
<br /> �: / f� ��, ar from to ft. ❑ yds. ❑ bags
<br /> ;' (`. f ,,,,�.s.,�( �Y`'nE.'r�� /� � �� from ro ft. ❑ yds. ❑ bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION �
<br /> � j';jr .,y�, � /ti 2� J ����' �.� feet L✓ direction,�b'�J,.;::,r.. ��d.�'LtyPe
<br /> � '�7
<br /> . Well disinfected upon completion? ,p Yes ❑ No �
<br /> ,�� ��.
<br /> �
<br /> .f �.A� '=7�'.� �t'!'�� ��4/ PUMP , .
<br /> ❑ Not installed Date installed � f I J � rI t
<br /> Manufacturer's name r��..,,.�.,;7�'i•,
<br /> � Model number �' S"'�0 i'Y1 HP •�i Volts ���j n
<br />� Length of drop pipe � y ft. Capacity ��„ g.p.m.
<br /> Pressure Tank Capaciry �? � Z,
<br /> Type: p Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
<br />� r
<br /> R
<br /> ABANDONED WELLS
<br /> s_.� Does property have any not in use and not sealed well(s)? O Yes �O.No
<br /> 1�
<br /> WELL CONTRACTOR CEFiTIFICATION
<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,il needed � � � ! S � �
<br /> � �.r--����J �� ,� :;f- � � .� �
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. L�censee Busrness Name _ �r' Lic.o�Reg.No.
<br /> �Ef y/�—;-'7 �� � � / � `✓I � L
<br /> �utho zed Represent� atiJ�2"Signature � � Date
<br /> �.,..� "%'/% ..r�!'�.1' �i�..L-v:.c�, // i .'�'-� �--
<br /> Name olOrille� Date
<br /> D E G 2 �:'��'
<br /> LOCAL COPY ��„ 3 8 9 5 He-o,zos-oa�Re�.sisz�
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