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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELLRECORD 5 6 3 2 <br /> (l Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fractio�.n{� � WELL DEPTH(completed) Date Work Completed <br /> (\v , � �� � 1'W 1 Evl�•1v./tiv. 1dt n. '7 <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD 1 <br /> L ? 7 711 Cable Tool ElDriven ❑ Dug <br /> N . .u! v ✓ r >^r..i ❑ Auger W Rotary ❑ Jetted <br /> Show exact location of well in section grid with'X.. Sketch map of well location. ❑ <br /> j Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> 14 <br /> ,USE Domestic ❑ Monitorin ❑ Heating/Cooling <br /> -�- -=- �- �- •, g <br /> IN i ; t E� N� ❑ Irrigation ❑ Public ❑ Industry/Commercial <br /> -1- -�- -,- _- ❑ Test Well ❑ Dewatering O Remedial <br /> f-mi. '�}`'-��, � '(` CASING Drive Shoe? ❑ Yes 97 No HOLE DIAM. <br /> -'- - -r- I `-.--r-' ❑ Steel ❑ Threaded ❑ Welded .' <br /> i , 1 <br /> fi7 Plastic ❑ <br /> �—l milr r q <br /> Oil <br /> r 1 <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME ff <br /> I,,.to 9 ft. lbs./ft. -it-in.to ft. <br /> in.to ft. lbs./ft. "r in.toJtlk. ft. <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> I} Make �f L..., Q A from ft.to ft. <br /> Type G. Diam. n <br /> Slot/Gauze 11 Length J <br /> Set between I ? k ft.andft. FITTINGS: X it i7 N< F <br /> HARDNESS OF STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 911 ft. below ❑ above land surface Date measured �� <br /> PUMPING LEVEL(below land surface) <br /> If kI1 ft. after L hrs.pumping a J g.p.m. <br /> l •1 WELL HEAD COMPLETION r <br /> CK Pitless adapter manufacturer i..-F_ '" C� Model LI Y <br /> V 1 pf C� ❑ Casing Protection ? 12 in.above grade <br /> _�� (. a d GROUTING INFORMATION <br /> Well grouted? kW Yes ❑ No <br /> ���•y J \ C , S ` ,G_'a. Grout Material �a Neat cement AD Bentonite <br /> J t <br /> from to1.4 N ft. _ �W yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> C.J feet direction L,,O# type <br /> Well disinfected upon completion? (K1 Yes ❑ No ,-,Q <br /> PUMP r <br /> ❑ Not installed Date installed <br /> Manufacturer's name f P W5: <br /> Model number HP„ Volts �k <br /> Length of drop pipe /_� ' ft. Capacity 1 g.p.m. 1 <br /> Pressure Tank Capacity <br /> Type:p7 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)?,A 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 thffis report is true to the best of my knowledge. <br /> Use a second sheet,if needed tl _ I f r(- "� -7 \ ,:(_J <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. <br /> � j <br /> AtSthoBzed Pirpresentative Signature Date <br /> Name of DrAgr Date <br /> LOCAL COPY � 535632 HE-01205-04(Rev.5/92) <br />