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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name F:E.�TLa->F,r._Fi.n WELL RECORD 532581 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. - Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> 4615 7orixaviev. lzjw. Clrorio, Mr.. ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger EJ Rotary ❑ Jetted <br /> Show exact location of well in section grid with W. Sketch map of well location. ❑ <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> I i <br /> t tUSE E?�Domestic ❑ Monitoring ❑ Heating/Cooling <br /> :.,r E,, 1i,: r ElIndustry/Commercial <br /> E ❑ Irrigation ❑ Public <br /> —�— T El Test Well ❑ Dewatering O Remedial <br /> CASING Drive Shoe? 9 Yes ❑ No HOLE DIAM. <br /> --t— — —; —r- I ❑ Steel ❑ Threaded ❑ Welded <br /> ' 1 li!�Plastic ❑ <br /> CASING DIAMETER WEIGHT J <br /> PROPERTY OWNER'S NAME / /�/�/, <br /> in.to ft. Ibs.ttt. O /in.to •` ft. <br /> Ge(,Me Suntawsju �T�. 7/P <br /> in.to ft. Ibs./ft. _m.to Mfr . <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. _in.to ft. <br /> QbttJt i Aw!• th SCREEN���R OPEN HOLE <br /> ? 7 <br /> Maple ove, 14n. 55,311 t Make from�ft.to ft. <br /> Type Diam. <br /> SIoUGauze i Length <br /> Set between 1 ft.and fy, ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO 1 G� <br /> MATERIAL ft. rti below 11 above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> i f <br /> Clayt7 at ft, after hrs.pumping 9.p-m. <br /> WELL HEAD COMPLETION WhitE''wn:— r <br /> ,1(:+ 6;),t LK Pitless adapter manufacturer Model <br /> ❑ Casing Protection X7 12 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? %/E7 Yes ❑ No <br /> Grout Material ❑ Neat cement R Bentonite <br /> from /` to C t ft. 5 IN yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? 1't� Yes ❑ No <br /> PUMP 6-26-93 <br /> ❑ Not installed Date installed <br /> Manufacturer's name Myers <br /> Model number HP Volts <br /> Length of drop pipe 146ft, pacijf_1 g.p.m. <br /> Pressure Tank Capacity ball <br /> I! %J0 1 <br /> Type: 49 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes X 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,it needed IXA S'XD-)1,A "K.1 MULLING CO., INC. 271-12 <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> F.P. A'lct k' i ton <br /> Name of Driller Date <br /> LOCAL COPY ---T532581 HE-01205-04(Rev.5/92) <br />