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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> WATER WELL RECORD M/NNESOTA UNfQUE WELL NO. A `� /� � O C <br /> Caunt Name , �- � <br /> Y dH��ro srorwra tsea.oi�.os fo.war�.saMp�e F J � t� V <br /> Townahip Name� , ownship Number Range Num6er Section No. fraction 4.WELL DEP"fH(compkted� Dare of Completion <br /> N E � ,� �b �� J <br /> .. - . . -Sf °r `y aX� � ft. �' �� �� � l <br /> Distance and Direction(rom Road(ntersection or Street Address and City of Well Location 5.DRILLING METHOD <br /> lO Cable tool 40 Reverse 7p Driven !00 Dug <br /> ow exact location d well in section grid with"X." Sketch map of well laation. 2O Hollow rod 50 Air 8C]Bored 11O <br /> N <br /> � � � i Addition Name ;i�e Ro[ary 6O Jetted 9O Power�auger <br /> --r- t -i 1- 6.DRILLINGFLUID <br /> � ' i i <br /> W •-i- -;- ;- �- E lock Number 7. USE <br /> _1_ _1_ _'_ S_ T '4�7 Domestic 40 Monitonng 8C]Hea[Pump <br /> I i � �' Lot Number 20lrrigation SO Public 9�Industry <br /> ' f mi. <br /> � � i I 3�Test Well 6�Municipal IOO Commercial <br /> '-�- �- - -�" 1 7L7AirConditioning IIO - <br /> t <br /> H—����t 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME HEIGHT:Above/Below <br /> lO Black dO Threadcd <br /> - Surface ft. <br /> 2O Galv. $p Welded <br /> Address � � . ' � - Drive Shce? Yes—No— <br /> 3Q Plastic 6p <br /> . `� in.to � tt. Weight Ibs./(t. _�n. to_ft. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to tt. Weight IbsJ(t. —in. to—ft. <br /> FORMATION <br /> in.to ft. Weight Ibs./ft. �n. to-�t. <br /> ' �.�f 9.SCREEN Or�open hole <br /> from (t.to. tt. <br /> Make <br /> � . .�.Yce . . -.. Dis. � <br /> SbVGauze L¢ngth �= - <br /> F17"f[NGS: <br /> Set between ft.and it. <br /> 10. STAT[C WATER LEVEL <br /> tL O below ❑above Date Measured � ,f <br /> land surface <br /> 11. PUMPING LEVEL(6elow iand surtace) <br /> 3 . <br /> - ft.after hrs.pumping ' g.p.m. <br /> f[.after hrs.pumping g.p.m. <br /> ' L' � 12.HEAD WELL COMPLETION ,,,- <br /> , � '� �. t�Pidess adapter.manufacturer � � model _ <br /> � <br /> 2O Basement offset 3O At leas[12"above ground <br /> 4O Plastic casmg protection <br /> 13.WELL GROUTED? <br /> 4 Yes ❑No <br /> lONeat Cement 2C]Bentonite 3O <br /> Grout material trom to,�,�_ft.cu.yds. <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> � feet - direction ' type <br /> Well disintected upon rnmpletion? O Yes ❑No <br /> 15.PUMP <br /> Date installed ❑Not installed <br /> - Manutacturer's name ~ <br /> Model number " HP Volts � <br /> Length of diop pipe ft. capacity g.p.m. 'k <br /> Material ot drop pipe � <br /> Type:.dp Submersible 3O L.S.Turbine 5O Reciprocating <br /> 2�Jet 40 Centrifugal 6O <br /> 16. EXISTING WELLS <br /> Unused well on property? j�57,yes ❑No <br /> Use a second shee(,if needed <br /> 17. REMARKS,EIEVATION,SOURCE OF DATA,etc. Abandoned � Permanent❑ Temporary❑ Not seakd <br /> • 18.WATER WELL CONTRACTORS CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best ot my <br /> knowledge and beliet. <br /> Licensee Business Name License No. <br /> Address '� � � <br /> i <br /> i ' <br /> ' Signed � - Da[r '�/� ,� <br /> � - Authorized Representative <br /> ;�l � . . _... .. _.. Date % .. :j� .7 . <br /> -Name of Driller <br /> S/74 30M <br /> 7/76 30M <br /> �o��� ���� 4 3 4 2 8 6 „�B� <br /> HE�01205�02(Rev.10/85) p���q„� <br />