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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
<br /> County Name WELL RECORD � 5 3 5 6 3 4
<br /> �.�;.. �;r� Minnesota Statutes Chapter 1031
<br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
<br /> � � y� `y� �. 1�I v�� v.�`�� i. , a. ,� � r-,��(
<br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
<br /> � { C Cable Tool ❑ Driven ❑ Dug
<br /> , � r r ' i;b ❑ Auger �J Rotary ❑ Jetted
<br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑
<br /> Showing property lines,
<br /> ry �` � roads and buildings. DRILLING FLUID
<br /> I � � i IV�
<br /> i
<br /> __r__y_ _1 _L_ —t ��....:�i ? ; ✓
<br /> �- �
<br /> i � � � � ,USE Domestic ❑ Monitorin � Heating/Cooling
<br /> --+- -=- �- �- � 9
<br /> W i ; i E ❑ Irrigation ❑ Public ❑ Industry/Commercial
<br /> _1_ _i_ __ __ T ❑ Test Weli ❑ Dewatering � Remedial
<br /> 1 � '
<br /> f-mi ��,° CASING Drive Shoe? ❑ Yes Q�,Na HOLE DIAM.
<br /> --;- �- � -�' I �� � ❑ Steel C Threaded ❑ Welded -
<br /> 1 Plastic ❑
<br /> ~—I milr�—� �" 1 �
<br /> �� �: i t
<br /> CASING DIAMETER WEIGHT
<br /> PROPERTY OWNER'S NAME C-�__in.to_���ft. �bs./R f�in.to'�'�!; ft.
<br /> . ���....{ l � �y �a�..:.� in.to ft. Ibs./R �in.tq�_�_~fl.
<br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. - in.to tt.
<br /> SCREEN OPEN HOLE -
<br /> ,r t�.
<br /> J; � ��� ,�. (_.:,� : . � � . . . ,. Make—z� �y,i,C��^ from ft.t ft.
<br /> �
<br /> Type << Diam.
<br /> SIoUGauze /� Length t
<br /> .. .~�., . ,_. 1�� ,:--. :, �� �.,,; ."," � � � Set between ��� ft.and�_��'�_ft. FITTINGS: 5_� t� ��a e J F� .
<br /> , I : . �'' . .. ��., ..
<br /> STATIC WATER LEVEL
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO �
<br /> MATERIAL ��� ft�below ❑ above land surface Date measured�
<br /> PUMPING LEVEL(below land surface)
<br /> (` t=` , ��r v, Y�\ �,, � j� � � 'a ft. after �„ hrs.pumping �, g.p.m.
<br /> WELL HEAD COMPLETION . t: :
<br /> �� 1 �,4 �t. y�, f � �l� t+j,. �l Pitless adapter manufacturer�v'�..,���. �n)��P�' Model tl �X ��a
<br /> � ❑ Casing Protection �1 12 in.above grade
<br /> ( �..^ j � '_���.�,� ,,,�,C ,. y.,ti ���{j I�(,� GROUTINGINFORMATION
<br /> t,
<br /> � � Well grouted? �] Yes ❑ No
<br /> r- �` `f � w�+ � ��� ��� Grout Material ,Q Neat cement �l Bentonite`
<br /> !/' /
<br /> _ from_�__to �(� ft. i _� yds. ❑ bags
<br /> i , , from to ft. C] yds. ❑ bags
<br /> t 1 ,
<br /> �,..J.�... t€' � =-,b^!i �C�,� �>t� �y..� from to fl. ❑ yds. ❑ bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> �}( � feet �'� direction r�'..•'-"�,�•�[ type
<br /> Well disinfected upon completion? �7 Yes ❑ No
<br /> PUMP
<br /> �l1
<br /> ❑ Not installed Date installed ,- iq,:�_ �}
<br /> Manufacturer's name ��i�,r y+'�,� � i
<br /> Model number HP�____ Volts �j�
<br /> Length of drop pipe��� ft. Capacity /1.g.p.m.
<br /> Pressure Tank Capacity��? !f �.��, (
<br /> Type:�1 Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
<br /> S
<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 /> Use a second sheet,il needed •,_`•;�, ��r�. 4� /�,.J
<br /> � � Y
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No.
<br /> _ e ir•,,. I ;�.vl..- "7.- .y�
<br /> /'�� � '�� � Authorized Representative Signature ~Date
<br /> .�- ...T�JI/ L/'. ..
<br /> 5 c �� ra �
<br /> h_� � r �� ',." -
<br /> Name of Driller Date
<br /> Laf:AL CQe'°� � � � � � ,� HE-01205-04(Rev.5/92)
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