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• <br /> F LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CoapfName," WELL RECORD 561334 <br /> -• Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> • 11 ,i <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> -. - - t ❑ Auger ❑ Rotary 0 Jetted <br /> Show exact location of well in section grid with"X'. Sketch map of wellyofiation. ❑ <br /> Showing properflines, <br /> N 1 roads and b6il ings. DRILLING FLUID <br /> 1 t <br /> � i -• ,USE ❑ Domestic ❑ Monitoring ❑ Heating/Cooling <br /> W I 1 E to tl Irrigation ❑ Public ❑ Industry/Commercial <br /> ❑ Test Well ❑ Dewatering ❑ Remedial <br /> 1 - -- - - T e ❑ <br /> Y.^" k wel. so CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> --- - - ---r- I 0 0 Steel ❑ Threaded [7 Welded <br /> � 1 <br /> I mil, vy ❑ Plastic ❑ -- <br /> \ CASING DIAMETER WEIGHT <br /> I <br /> PROPERTY OWNER'S NAME in.to ft. '_ lbs./ft. in'to ft. <br /> xeri an Construction in.to ff. lbs./n. ;t. =ft. <br /> Mailing address if different than property address indicated above. -- _- _._ in.to _ft. _ lbs./ft. in to ft. <br /> fit. 4, box 385 SCREEN OPEN HOLE <br /> 77 }. Mn {{�� (� Make t.ii.f.Llibirt.On from ft.to ft. <br /> Eani, Type '.t,_-J. ,ess Steel Diam. 4 ---.. <br /> Slot/Gauze - 1;j4//L j Length <br /> Set between, .1 ft.and 1 ft. FITTINGS: 1 1 l . .` <br /> I <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO - ft. ❑below ❑ above land surface Date measured <br /> MATERIAL <br /> PUMPING LEVEL(below land surface) <br /> - 1' / ft. after i hrs.pumping -- ? --•._ g.p.m. <br /> WELL HEAD COMPLETION <br /> . _y-1 I. ,A.. Grey a - ' Q,Pitless adapter manufacturer E1:j-t3 to Latey- Model <br /> ❑ Casing Protection 0 12 in.above grade <br /> :.-;a ci-Gra el. Tani _ - - GROUTING INFORMATION <br /> Well grouted? :.0 Yes 0 No <br /> Grout Material 0 Neat cement U Bentonite <br /> from . 'to ft. ❑ yds. 0,bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATIONIN� <br /> L. /� <br /> `S-0 feet /�✓ direction21G/ type <br /> Well disinfected upon completion? !J Yes 0 No <br /> PUMP f)-I )-9E; <br /> ❑ Not installed Date;installe_d <br /> Manufacturer's name `1'V(.-'a; __ <br /> Model number . L.`)L5 HP Volts G-,'' <br /> Length of drop pipe ? ii ft. Capacity g.p.m. <br /> Pressure Tank Capacity i ,, C-1(7'.H.':' <br /> Type: 0-Submersible 0 L.S.Turbine 0 Reciprocating 0 Jet 0 <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ 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 /> . .h-1 vaa,.i, ardi..L114:4 (.1.)., LLD <br /> Use a second sheet,if needed r <br /> REMARKS,ELEVATION,SOURCE OF`1?AT4,(r. ly9v Licensee Business Name Lic.or Reg.No. <br /> Al V <br /> Authorized Represents $SignaEure Date <br /> Name of Driller Date <br /> LOCAL COPY 561334 HE-01205-04(Rev.5/92) <br />