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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD 2 217 6 <br /> l ' <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) 7i7ompleted <br /> t <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger ZRotary I I Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> N fgaclF sand buildings. DRILLING FLUID <br /> I I I �� t.-__,•- � r <br /> , <br /> i ,USE I-.1 Heating/Cooling <br /> -❑ Domestic ❑ Monitoring <br /> -+- --- �- �- - ❑ Industry/Commercial <br /> W , i EElIrrigation ElPublic <br /> El Test Well El Dewatering O Remedial <br /> CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> Cl-Steel ❑ Threaded ❑ Welded <br /> , 1 <br /> ❑ Plastic ❑ <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME ! in.to / ft. / lbs./ft. in.to - ft. <br /> j in.to ft. lbs./ft. in.to" ft. <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make from - ft.to <br /> Type Diam. <br /> Slot/Gauze Length <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO ft. K below ❑ above land surface Date measured <br /> MATERIAL <br /> PUMPING LEVEL(below land surface) <br /> -j....">..I �>:-....�.t - - :'.1(• --- ft. after._ ..hrs.pumping g.p.m. <br /> �- WELL HEAD COMPLETION <br /> / �rz�. p Pitless adapter manufacturer�! "� -F' __ Model <br /> `, ❑ Casing Protection L 1 12 in.above grade <br /> 1<. •/ G'!•'%a� �. .!�`} GROUTING INFORMATION <br /> Well grouted? ❑ Yes k No <br /> Grout Material ❑ Neat cement ❑ Bentonite <br /> ( from to ft. ❑ yds. ❑ bags <br /> ._{ / �• , from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> r <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet 1 r 'a., direction . ..,. <br /> type <br /> Well disinfected upon completion? �1 Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed <br /> i <br /> -I• '' � „! /,7 �"'��' Manufacturer's name <br /> Model number HP J Volts <br /> Length of drop pipe ft. Capacity ,g-p-m. <br /> Pressure Tank Capacity <br /> Type: LS Submersible ❑ L.S.Turbine ❑ Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> C f J 419 Does property have any not in use and not sealed well(s)? ,(I 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 this report is true to the best of my knowledge. <br /> Use a second sheet,if needed ;`�j •r �l•;r/�,;>� <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. _ Licensee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> •Name of Driller Date <br /> MAR 1953 <br /> LOCAL COPY 522176 HE-01205-04(Rev.5/92) <br />