Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
J�IA 1-�UN MINN�JV l A UGt'AK 1 M�IV 1 UN tt�ALI t1 <br /> LOCAT[ON F L MINNESOTA UN/ UE WELL NO. '� <br /> mnry Name WATEfl WELL RECORD � n � � � '1 <br /> �.N.l eL��� �Llinnesofa Sfafufes I56A.01�.08 /or Wafer Snmp[e �+ 1 . �..,,� ... <br /> /�Y/r <br /> �wnship Name Township Nu Range Number Section No. Frac�n�r�� 4.WELL DEPTH(mmpleledl Uate of Complehp� <br /> ��� s �3 W 7�'r ' ' ��-{'.J f�. �/ � 3 �q l <br /> iumerical Street Address and City of Well Loca[ion or Distance r m Road Intersection. 5. DRILWNG METHOD <br /> 3�' ^ ���rt i 1„G ��' � ❑Cable'lool ❑Reverx ❑Driven ❑Dug <br /> J� ` <br /> Show exact location of well in section grid with"X." Sketch map o(well location. ❑Hollowltud ❑Air ❑Bored ❑ <br /> N <br /> � ' _1 _1_ Addition Name � �` �V� ❑Ro[ary ❑Jetted ower Auger <br /> � -~ � � �`� ?� 6.DRILLWG FLUID <br /> � � i �1 N�N� <br /> -_�_ ___ �_ �_ BlockNumber � <br /> yy � ; I � E �W T �! 7. USE <br /> i <br /> _1_ _1_ _�_ , � ❑Domestic onitoring ❑Heat Pump <br /> I � ' � Lo[Number ❑Irngation �ublic ❑Industry <br /> � 1 'f_•mi. ^^` ^- . 'I � <br /> i ❑"I�est Well �O Munici 1 ❑Commercial <br /> I \..(./ f�p b <br /> --i- �- - -r'- 1 .� ❑Air Conditioning ❑ <br /> ' ' � V <br /> ; �m��e ' � � 8.CASWG �.r ���D� HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if differen[[han property address lack {� IGHT:A ve/Be ow <br /> �B I��7 Threaded <br /> indicate above. � " Surface d f�. <br /> Q�y, ❑Galv. ❑Welded <br /> ��r� /y(i •I�/1ef1.,rT� ^ �' VwV (P� Drive Shce? Yes_ No.� <br /> ��� Ur (.//'CX.M�� � ❑Plastic ❑ '7�/ <br /> v��SI�'�+ . �'1� �� �in.to�ft. Weigh[ ��'� IbsJtt. 9.n. to�1t. <br /> 3. FORMAT[ON LOG COLOR HARDNESS OF FROM TO in.to ft. Weight IbsJtt. �n. to�t. <br /> FORMATION <br /> � in.to tL Weight IbsJfL —�n. to—�t. <br /> r i / <br /> 61 TV/�1 jN l�i.�s r/�•t. � / 9.SCREEN Or open Fwle <br /> D ar'�y) � � Make � n5 G,� from (t.to. (t. <br /> $��-� S.4r�D ca�Gl�VC L --�gl eteK� 5 O�'1' � � Trae C���t�i►-t��(tt.A .SS Dlam. �// <br /> ( / 7� ,/ Q i_ SbVGauze ��� ��'v�� � Length ��� <br /> J iL:� F�/1°��S4'�JJ Di� U:b��r'1 SO�' �, � f,Y �� FITTMGS: <br /> / Set between ft.and�(t. <br /> '�rc�d-�.al I <br /> ,s I L''��!/ (�N�i �•1t'!�� rn cA. I �f{�' J 10. STA»T�ICrW�A�ER L�L � <br /> / �� '�� �� `+�� e!-'L�s.(t beiow ❑above Dale Measured � �3/ <br /> I nd sur(ace <br /> 1%IN� Sq�,v,� +����L,s�/a' ��� /J�y� �y',' ( 11. PUMPING LEVEL(below land sur(aml <br /> A' "`t �� �� (t.a([er hrs.pumpmg g.p.m. <br /> ft.a(ter hrs.pumpin g.p.m. <br /> ��/ 12. HEAD WELL COMPLETION <br /> ❑Pitless adapter manufacturer Model <br /> 'O Basement,ottset ❑At least 12"above ground � �2�0� <br /> ❑Plastic casing protection <br /> O' <br /> 13. WELL GROUTED? 'Yes ❑No <br /> - �Ne��ement ��o,n�ite ❑ 'ry <br /> -�-�� Grout material �� from 0 to�ft.cu.yds. _ <br /> . #Z- �� `Z'Z <br /> la. ?vF;AKEST SOURCES OF POSSIBLE CONTAMINmATION <br /> ��_feet �YL direction '�[/'�•v M`� S)��-�ype <br /> ��rt� Well disinfected upon mmpletion? ❑Yes �No <br /> �'1 y <br /> Y�� C. 15. PIJMP <br /> • - Uate installed �Not installed <br /> Manufacturer's name <br /> Model numher HP Volts <br /> Length of drop pipe fL Capacity g.p.m. <br /> Material of drop pipe <br /> Type: ❑Submersible ❑L.S.Turbine ❑Reciprocating <br /> �Jet ❑Cenvitugal O <br /> 16. ABANDONED WELIS <br /> Unused well on property? O Yes �o <br /> Use a second shee(,iJ needeJ Sealed O Permanent ❑ Temporary ❑ Not sealed <br /> 17. REMARKS,ELEVAT[ON,SOURCE OF UATA,etc � <br /> '` • 18. WATER WELL CONTRACTOH CERTIFICATION <br /> ���L �, �'SS VGI��j� i 1v�. This well was drilled under my jurisdic[ion and lhis report is true to the best o(my <br /> ��i�(� �R M���Z'p ft,(/y�+ �j���5�� Fi�v-� knowledge and beleet. <br /> 1 <br /> 1N'��- d I�l]N�'�. ; i�.i C�til�k-RD �A �i�y ��'�N-�- ��S3vC/f�7�S� /7J c. . �i O(?�y'r <br /> � Li�enser Business Name Lirense No. <br /> 3�71� .Sho�'t l�n� D2• Add�e�.�i�M / S 27 <br /> p Q.or.�o , r►,r� 553R Z 7, /y--9� <br /> Signed �� Uate V^ <br /> �eyp2 /�� /� � y,.� +� Aufhorized Represen(atiue j / <br /> �1�1J �V 1�7�i f"C.ILl���� t`� �ZZ� �W�I i�� � a�Q'f � Date � /D �'I/ <br /> me o(Dn l(er I <br /> IMP�RTANT: i iesonMn ` <br /> FILE V1�ITH �EED — WELL OWNER COPY 477 614 HE-01205-03(Rev.9/88) ziez oM <br />