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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CounlyName WELL��RECORD � -� � �� <br /> ` Minnesota Statutes Chapter 1031 `^' -y- � � ' � <br /> Township Name Township No. - Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n <br /> v v. <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". �c�c, Sketch map of well location. ❑ <br /> J oY Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> � � i <br /> __r_ t _i _L_ <br /> i � <br /> � � � � ,USE ❑ Heating/Cooling <br /> __+_ _�_ _ �_ �Domestic ❑ Monitoring ❑ Industry/Commercial <br /> yy � � I E ❑ Irrigation O Public ❑ Remedial <br /> ' , T ❑ Test Well ❑ Dewatering <br /> _1_ _1� __ S_ I ❑ <br /> � � � <br /> f-mc CASING Drive Shoe? ❑ Yes � No HOLE DIAM. <br /> ' ' ' 1 <br /> —�— �— — r- ❑ Steel � Threaded ❑ Welded <br /> � � <br /> � Plastic JQ (31� <br /> � �rnile—� ' <br /> CASING DIAMETEA WEIGHT <br /> PROPERTY OWNER'S NAME 4 in.to �3 ft. Ibs./ft. � in.to+�8 R. <br /> J. p� in.to fl. Ibs./ft. in.to ft. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs.ttt. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make J(� from ft.to ft. <br /> Type �^ Diam. <br /> SbUGauze v1.g Lengt <br /> � Set belween �3 ft.and�tt. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO �e 1n <br /> MATERIAL '�e.l h� �below ❑ above land surface� Date measured 08/1L/92 <br /> _ _ PUMPING LEVEL(below land surface) <br /> �y Q � ft. after_ hrs.pumping 1� g.p.m. <br /> WELL HEAD COMPLETION <br /> �� � t�n^aZ�Dl � �Q �Pitless adapter manufacturer ��.�ca Model � <br /> y..��... <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> S[ � � 3O 55 GROUTING INFORMATION <br /> Well grouted? �Yes ❑ No <br /> Cl.c1y gray 55 �,� Grout Material II Neat cement ❑ Bentonite <br /> X <br /> �� from �to_�_ft. ❑ yds. ❑ bags <br /> _�,�'w /�,, 1Gn from to ft. ❑ yds. ❑ bags <br /> ►��� �t S�Y��.c �/a�l 1�0 1�7V from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Z('Y'a�l & $a� r� y� 178 feet _ direction rype <br /> Well disinfected upon completion9 ❑ Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed�ABT�QT/O'Z' <br /> Manufacturer's name 1+�..,7.i.. <br /> Model number HP�_ Volts��.__ <br /> Length of drop pipe �_tt. Capacity � g.p.m. <br /> Pressure Tank Capacity <br /> Type: {�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> C Does property have any not in use and not sealed well(s)? ❑ Yes No <br /> CITY 0 � <br /> WELL CONTRACTOR CERTIFICATION <br /> , �� � This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,il needed S'�{�$ �,]► , �t��7�7 (;Q.� Ij�`� 86659 <br /> REMARKS,ELEVATION,SOURCE OF DATA,eta Licensee eusiness Name Lic.or Reg.No. <br /> . ;-� .. �� ,, -�. <br /> �E F� 1 1 'i�9� � ...«. � _ _--�_. <br /> Authorized Rept sentative Signature <br /> Rax�dv Jd�nsan 08/12/92 <br /> �" ame oi Driller Date <br /> LOCAL COPY 514 2 7 5 HE-01205-04(Rev.5/92) <br />