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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1.LOCATION OF WEM Count Name WATER WELL RECORD MINNESOTA UNIQUE Sam WELL NO. /I 3 8 ^ 6 r <br /> County i for Wafer Sample [�s{1 iD,(!`f'TI t <br /> Minnesota Statutes I56A.01-.08 ' <br /> Township Name I rwrship Number Range Number I Section No. I Fraction 4. WELL DEPTH(completed) Date of Completion <br /> 1/4 <br /> F VNW F•'_ or or <br /> W a'',.' ...F�J (l. =c.. pi' •.F� <br /> Distance and Direction from Road Intersection or Street Address and City of Well Location 5.DRILLING METHOD <br /> 10 Cable tool 40 Reverse 70 Driven 100 Dug <br /> Show exact location of well in section grid with'X." Sketch map of well location. 20 Hollow rod 50 Air 80 Bored 110 <br /> M <br /> Addition Namezo Old ; :GRotary 60Jetted 90 Power gauger <br /> r- t- <br /> -1 6.DRILLING FLUID <br /> Block Number +R.if <br /> W i ; I E 1 <br /> i Domestic 40 Monitoring 80 Heat Pump <br /> 1 i <br /> '12 Lot Number r 20 Irrigation 50 Public 90 Industry <br /> m:. 1 <br /> � � 1 30 Test Well 60 Municipal 100 Commercial <br /> 70 Air Conditioning 110 <br /> mile's i !' HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME i I� f HEIGHT:Above/Below <br /> f 10 Black eldeded ' <br /> Surface (t. <br /> ;J -�N�. ►..___„ ten` 2❑Galv. 50 elded <br /> Address /, .. �`�t�Tx �;p ,.,f �y,tY Drive Shoe? Yes— No--W-- <br /> 26> <br /> o W4 <br /> 26> U”.. t&.Y �"'Y Rd* U sic 60 <br /> .,t <br /> r <br /> j.! Zi•�' 3 roi'J °-. 14 in.to ft. Weight :aJ$ `f06./ft. in. tort. <br /> 3. F MATION TO <br /> FORMAS ON g <br /> LOG COLOR HARDNESS OF FROM in.to ft. Weight lbs./ft. —gin. tort. <br /> •-• <br /> in.to ft. Weight lbs./ft. in. tort. <br /> ? 9.SCREEN Or open hole <br /> from ft.to. ft. <br /> Make <br /> y.9•, Type "A11"ALUM& Itefil Dis.Md lei <br /> Slot/Gauze �' Length 1 J <br /> I ,. FITTINGS: <br /> `.a}'r al <br /> Set between ft.and ft. <br /> • 4 10. STATIC WATER LEVEL <br /> blue Ned <br /> t p�j ft.LD below ❑above Date Measured ��t+(y� � <br /> Ian surface <br /> yell L-.11 <br /> 11. PUMPING LEVEL(below land surface) <br /> elw -4 ici 4 i s,'`y ft.after ii hrs.pumping L'iL 9-P in <br /> ft.after hrs.pumping g.p.m. <br /> °✓ ida�.il� rtP-�xra L 12. HEAD WELL COMPLETION <br /> 10 Pitless adapter.manufacturermodel <br /> 1 2b Basement offset 3k At least�l2"�above ground <br /> .4iifir 'Tavel li 't blUi e(, 40 Plastic casing protection <br /> -} i 4 13.WELL GROUTED? <br /> d. <br /> ikht f'J f 4 p Yes ❑No <br /> 10 Neat Cement 20 Bentonite 30 <br /> -- �` -- -- , 6Grout material froml U._to 'A ft.cu.yds.-- <br /> urk ILL.;- <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? LVes ❑No <br /> Vel ig,a. o-,. :. ..... +� t3h15. PUMP <br /> Date installed 7'3/e,•1.''-'? ❑Not installed <br /> - - - Manufacturer's name— <br /> . ..-.,__. .._ __ ... . ..c <br /> Model number .. HP_,_,•_�Volts <br /> --- -- _ ` Length of drop pipe 126- ft. capacity g.p.m. <br /> 4 Material of drop pipe wvc <br /> �..__ ___— - +• Type:10 Submersible 30I.S.Turbine 50 Reciprocating <br /> 20 Jet 40 Centrifugal 60 <br /> 16. EXISTING WELLS <br /> Unused well on property? ❑Yes f1 No <br /> Use a second sheet,if needed a. <br /> 17. REMARKS,ELEVATION,SOURCE OF DATA,etc. Abandoned ❑ Permanent 0 Temporary❑ Not sealed <br /> 18.WATER WELL CONTRACTORS CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. <br /> •C,• `Li`tenser 'nd3-Near da •- <br /> r <br /> Signed Date <br /> Authorized Representative <br /> Dat <br /> Azi Stevemg Name of Driller / 7 <br /> 438460 7/7630M <br /> LOCAL COPY 7/7830M <br /> HE-OI205-02(Rev.10/85) 2/82 10M <br />