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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1.LOCATION OF WELL IWATERWf4.L REGARD MINNESOTA UNIQUE WELL NO. <br /> County Name//_J <br /> l _f"teH--74,,,, " Minnesota Statutes 156A.01-.08 for Water Sample <br /> 477415 . <br /> Township Name / Township Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> E <br /> f 11.-�tn^-gr 1 / 7 1 .),3' or 3 i wt <br /> . -V+4,1,e se / I/s-- ft. 7— 3 9/ <br /> Numerical Street Address and City of Well Location or Distance from Road Intersection. 5.DRILLING METHOD <br /> CICable"fool 0 Reverse ❑Driven 0 Dug <br /> Show exact location of well in section grid ith"X." ? Ske h map of well location. 0 Hollow Rod 0 Air 0 Bored ❑__ <br /> N <br /> t Addition Name RRotary ❑Jetted ❑Power Auger <br /> -_ .__y_ _1-_1_ ' <br /> t t t A. 6.DRILLING FLUID <br /> 1 <br /> W i i_ E <br /> I Block Number 7. USE <br /> t - - I w,,,..�._- <br /> __ ..... i4Domestic 0 Monitoring 0 Heat Pump <br /> I Lot Number ❑Irrigation 0 Public 0 Industry <br /> mi <br /> ❑Test Well ❑Municipal 0 Commercial <br /> ` - - -r- ( ,� f .,/ 0 Air Conditioning 0 - £'; <br /> I--1 mile 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNERS NAME Mailing Address if different than property address ❑BlackHEIGHT:Above/Below ,fir <br /> ❑Threaded : ::. <br /> indicated above. Surface ft. <br /> ❑Galy. 0 Welded <br /> /`/• Drive Shoe? Yes_No <br /> .w-/ i ,t-/.j/�"+ I 'Plastic ❑ ,. <br /> '1+" tl in.to /If/ft. Weight—144„t._lbs./ft. -en. tort. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight lbs./ft. 4-in. tc Ft. <br /> FORMATION <br /> in.to ft. Weight lbs./ft. _in. to_ft. <br /> %' <br /> '' /.....) 0 Y3 9.SCREEN Or open hole <br /> 1 1 �=�t rt----1 i <br /> Make ..r"^.-•• from ft.to. ft. <br /> �^ fifr/' / �j f _ /' f <br /> r dCR'-----. / e r '7 ? I Y Type _.41.e .--.kiL.a-+ .. r�! Diem. J <br /> L. / Slot/Gauze f) Length <br /> t; FI4INGS: <br /> ..zet-^.-e• `j (.. _..d�-ill � 1�.�t_!.-.x. f �� f✓!f Set between t of (t.and r r! j(i. <br /> ✓J I{ 10. STATIC WATER LEVEL <br /> .1.1�1--4)"--41 req - (-17"-'1..1.1 j,/f / 1/i— 4--j fL below ❑above Date Measured 7 ., GI. <br /> r;/ lasurface <br /> II. PUMPING LEVEL(below land surface) <br /> Sl ft.after f hrs.pumping ,y) I— g.p.m. <br /> ft.after hrs.pumping g.p.m. <br /> 12. HEAD WELL COMPLETION f <br /> Witless adapter manufacturer Model d - '/ . I <br /> '❑Basement,offset ❑At least 12"above ground <br /> ❑Plastic casing protection <br /> 1 r " cm <br /> I3.WELL GROUTED? Yes 0 No <br /> nr3nran <br /> ��w//7M L ) Cleat Cement ❑Bentonite ❑ <br /> `' `---'`---� Grout material from 5 0' to C) ft.cu.yds. . <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> AUG 5 1991 6 0 feet .s 4.. direction -1 . .._.. /4'172, x. <br /> Well disinfected upon completion? ilL,Yes ❑No4,-. <br /> 15. PUMP <br /> Date installed 0 Not installed <br /> Manufacturer's name <br /> Model number HP Volts <br /> Length of drop pipe ft. Capacity _ __ _--g.p.m. <br /> Material of drop pipe <br /> Type: ❑Submersible ❑L.S.Turbine ❑Reciprocating <br /> ❑Jet 0 Centrifugal ❑ <br /> 16.ABANDONED WELLS <br /> Unused well on property? Nes 0 No <br /> Use a second sheet,if needed Sealed Permanent 0 Temporary 0 Not sealed <br /> 17.REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> • 18.WATER WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. 7 <br /> 4. <br /> Licensee Business Name }f/�' j License . <br /> Address t/ _I' ? i //• l 1 fre- ' ..f'- <br /> Signed //11L1- . -• -e•44"..6.1 <br /> . s - Date 7 . !/-4,.�f Authorized Representative <br /> '_-"fin. C7 7-1;--4,10.-- , Date 7 .. .1- <br /> Name of Drille <br /> 4 7 7 415 5/74 30M <br /> 7/76 30M <br /> LOCAL COPY HE-01205-03(Rev.9/88) z 82 t0M <br />