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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1' WATER WELL RECORD MlNNESOTA UN/QUE WELL NO. �A���� <br /> Cwnty Name Im Wafer Samp/e b <br /> ' - ���i � Mie�esola Slatwfes 156A.0I�.08 <br /> Township Namei . ownship Numher Range Number Section No. Fraction 4.WELL DEPTH(compkted) Date of Completion <br /> Ul�'IIG 1�I a G� µ UL�� �� �h / p.r.L3'"�."�ti I11�f F fl. L7'-.L.Ci'-7i1 <br /> Numeri yty_of m Road[ntersec[ion. 5.DRILLING METHOD <br /> �/L� O CableTaol O Reverse O Driven ❑p�g <br /> �.�'.��� ���:�2 3d1�"3�'� �..-'2:.11�'�: CiY.Y'`i'LCS t��,I2F1. <br /> ow exact location d well in section grid with"X." Sketch map of well loration. ❑HollowNod ❑Air ❑Bored ❑ <br /> N <br /> � � i i --�-�--- "�--��AdditionName ���- . _ . _, 4Rotary OJetted OPower�Auger <br /> '-r- y- -1 -1- ' . <br /> � � 6.DRILLING FLUID <br /> � , . ._.._- A Q <br /> •-�- -1- �- �- Blak Number �• t�/'�� <br /> W � � � E 7.USE <br /> i �,..��.��. <br /> _1_ 1_ _'_ __ - �� 4'�.Domestic ❑Monitoring ❑Heat Pump <br /> I ; � � . Lot Number -- ' - �r�J " - � � O Irrigation O Public ❑Industry <br /> 'E,m�. <br /> ' � � I ❑Test Well L7 Municipal ❑Commercial <br /> � � !� 1 ❑Air Conditioning ❑ <br /> I mile—� 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if diffe�en[than property address ❑g�ack HEIGHT:Above/Below <br /> ❑Threadtd <br /> indica[ed above. Surface (t. <br /> �`�i_:�k:� t Se:.ii�.1`:3,.,"f,:2!i. O Galv. ❑Welded <br /> O Drive Shce? Yes�No_ � �Jf«2 <br /> C��lastic <br /> � in.to �-��' tt. Weight ���l� Ibs./tt. �n. t��4 t. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight Ibs✓ft. �n. to�t. <br /> FORMATION <br /> in.[o (t. Weight Ibs./tt. �n. to�t. <br /> �� � �� 9.SCREEN Or�open hole <br /> n 1 Make J���� from ft.to. (t. <br /> �7e3�. 7� li..'� TYPe a.�t`+.i"3Ytil�S :3�rti1 Diam. „2H <br /> Slot/Gauze �� Length �; <br /> j`,,� FITTINGS: <br /> Set hetween # j ft.and�L1L�ft. <br /> 10.STATIC WATER LEyVEL <br /> �-7 (t.!}below ❑above DateMeasured �'�"`�"`�t3 <br /> land sur(ace <br /> 11.PUMPING LEVEL(below land sur(ace) <br /> -�� ft.after � hrs.pumping �=Z$ g.p.m. <br /> ft.after hrs.pumping g.p.m. <br /> 12.vEAD WELL COMPLETION <br /> [#SPitless adapter manufacturer��-� ��-� Modei _ <br /> ❑Basement o(fset �"A[least 12"above ground <br /> ❑Plastic casing protection <br /> 13.WELL GROUTED? q�'es ❑No <br /> 43Neat Cement D Bentonite L] <br /> t <br /> Grout material from ` to � (t.w.yds. <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direc[ion �ype <br /> Well disinfected upon rnmple[ion? �.Yes ❑No <br /> 15.PUMP <br /> Da[e installed ❑Not installed <br /> Manufacturer's name .— <br /> Model number HP Volts__ <br /> Length o(drop pipe f[. Capacity .g.p.m. <br /> Ma[erial of drop pipe __ <br /> Type: �Submersibie ❑L.S.Turbine LJ Reciprocating <br /> ❑Jet ❑Centri(ugal O <br /> 16. ABANDONED WELLS <br /> Unused well on�xoperty? O Yes �Plo <br /> Use a second sheet,if needed �� ❑ Permanen[ ❑ Temporary ❑ No[sealed <br /> 17. REMARKS,ELEVATION.SOURCE OF DATA,etc. <br /> 18.WATER WELL CONTRACTOR CERTIFICATION <br /> This weli was drilled under my jurisdiction and this reporl is[rue to the best of my <br /> knowledge and beliet. <br /> �.+�:!'i .�,d�l{L7:�1.Y1 YYy7rtfu aM�.L�.a6a�.t7c3 �li: 1t'N... G/i�6: <br /> Lrcensee Business Name License No. <br /> Address �,;?✓'i,'�? �1.���.i�� � �� ���'�t3� �"��1. �=7-:�C:J <br /> SiBned ,��r...��,r .���Date g"G7—��+' <br /> Au[hortzed presentatlue <br /> t. �. �li.'+I7 Date t?' - . <br /> Name oJDrtller <br /> LOCAL COPY �� � /� ` 5���� <br /> .� -;ry �ne� <br /> r '� ��- HE-01205-03(Rev.9/88) ziB2�O�AA <br />