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STATE OF MINNESOTA DEPARTMENT OF HEALTH • <br /> 11.LOCATION OF WELL] WATER WELL RECORD MINNESOTA UNIQUE WELL NO. 4 3 ('71 <br /> a M Minnesota Statutes 156A.01..08 W"'"-6aayk v... <br /> 15SA.01.08 S <br /> 'Township Name Township Number Range Number Section No. Fraction 4.WELL DEPTH(ixxnpleto., Date of Completion <br /> :oto II�} 4 2.+ a -?-.:_.` r t��►': y 1::. ft. 12/11/57 <br /> S W <br /> -Pistance and Direction from Road Intersection or Street Address and City of Well Location 5.DRILLING METHOD <br /> '\ 2'1400 (}i <br /> C) L6 f`ie€«,.8 t , lO Cable tool 40 Reverse 70 Driven 100 Dug <br /> JAM exact location we in section grid with"X." Sketch map of well locator= *3 Hollow rod 50 Air 80 Bored 110 <br /> - __Addition_ !flame--- <br /> J 6.DRIL Rotary <br /> 60 Jetted 90 Power;auger <br /> N <br /> 11111111111t b✓r .te <br /> W ®111111 E Block Number �---�- <br /> 7. USE <br /> 11101111111 Tome <br /> i lb Domestic 40 Monitoring e0 Heat Pump <br /> 14Lot Number 20 tion 50 Public 9O Industry <br /> 1111111111111/11 m. <br /> 3O lest Well 60 Municipal 100 Commercial- <br /> 70 Air Conditioning 110 <br /> I---1,.ik 8._CASING HOLE DIAM. <br /> 2.PROPERTY OWNERS NAMEHEIGHT:Ahave/BeIow <br /> .►# <br /> q ID Black 40 Threaded 2 <br /> I1'•I martiuson Surface it. <br /> !!j.vr 20 Galv. 50 Welded .. <br /> Address 1 i _. 1"ark r I: f t <br /> r r.^ 30 Plastic 60 t i; <br /> in.to ft. Weight lbs./ft. �~ n. toh <br /> _ . <br /> 3. FORMATION LOG COLOR HARDN FROM TO in.to ft Weight lbs./ft. _in. to—h. <br /> FORMATION <br /> t.T.-t� i <br /> i HiQi..Q, in.to ft. Weight lbs./it. ten. to—Jt. <br /> `�}',F%ti L.I C t-+a •,`„t -. 9.SCRE N Or open hole <br /> from ft.to. ft. <br /> Make relr <br /> c1$va sity+ six pe11 / Mal. I : q.. Type t3�!13@ steel Disi : Xio' . <br /> €f <br /> Slot/GauzeIMBt <br /> •i 1 X _ j,,,e4Z 'RTINGS: <br /> ',rley,a sne nix (int! Rte;,a 2..f.-., I I L° Set between ft.and ft. r W�`) <br /> 3, S ! i. ran ice'r <br /> t I7� I 10.STATIC WATER LEVEL 121/1/C7`_//f/C7 <br /> of tc": sari n' L a f =- ft.0 below ❑above Date Measured <br /> land surface <br /> nT�It81 I1. PUMPING LEVEL(below fay¢surface) <br /> S� ft.after hrs.pumping 2.p.m. <br /> ft.atter hrs.pumping . g.p.m. <br /> 12.HEAD WELL COMPLETION 6,---its. SP:C4 4e: <br /> 10 Pitless adapter.manufacturer model <br /> 20 Basement offset 30 At least 12'.above ground <br /> 40 Plastic casing protection <br /> ,t1,3.WELL GROUTED? <br /> 4 '❑Yes 0No <br /> r <br /> 10 Neat Cement c itie 30_ _. 17 r <br /> Grout material _from_ to ft.cu.yds. <br /> 14 NEAREST SOURCES.rOF POSSIBLE CONTAMINATION <br /> C teen '� direction SeWer _tyer <br /> Well disinfected upon completion? kl Yec 0 No <br /> 1fl j 15 PUMP t <br /> Date installed_ Irj15f — 0 Not installed <br /> t I Manufactur.,•s name ** j2�g 7{t f <br /> Model number -t:12511 HP 3+/4 -Volts 23C' <br /> Length of drop pipe— 10151 _.ft capacity 12.1_ _g.p.m <br /> Material of drop pipe GYvan <br /> anee <br /> 1 Type:TIP Submersible 30 L.S.Turbine 50 Reciprocating <br /> 20 Jet 40 Centrifugal 60 <br /> 16. EXISTING WELLS <br /> Unused well on property? 0 Yes 0 No <br /> Use a second sheaf,it needed Abandoned 0 Permanent 0 Temporary 0 Not sealed <br /> 17. REMARKS,ELEVATION,SOURCE OF DATA.etc <br /> 18. WATER WELL CONTRACTORS CERTIFICATION <br /> This welt was drilled under my Jurisdiction and this report is true to the best of my <br /> knowledge and belief.L t <br /> : r9atr a Il li ♦ 7w. � �. <br /> LI <br /> I Licensee Hrsi Na we Lamer,Na. <br /> Address f a �' <br /> Signed ._ 1. . Authorised Representative :. ���'}/ <br /> fi/11110arse fc_a.i%aat.Zt Date 't!..lirtA <br /> Name of Driller <br /> WAIEK WELL • <br /> 6iie30/4 <br /> 3oaa <br /> CONTRACTOR COPY <br /> 439711 7/7g � <br /> HE-01206.0¢(kev.10/85) 2/62 1004 <br />