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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1.LOCATION OF WEP WATER WELL RECORD MINNESOTA UNIQUE WELL NO. A <br /> County Name <br /> 47744 <br /> .�� mit-,-. <br /> Minnesota Statutes 156A.01.08 /or Wafer Sample <br /> -v-`- <br /> Township Name r It ownsrop Number I Range Number SectIion No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> E f _ <br /> /'rips / N IV <br /> -t,t,-- n. <br /> Nutnei•tcal Street Address and City of Mll Location or Distance f Road Intersection. 5. DRILLING METHOD <br /> J.—l. ElCableTool ❑Reverse ❑Driven 11 Dug <br /> how exact location of well in section grid with"X." Sketch mj of well location. ❑Hollow Rod ❑Air ❑Bored ❑ <br /> N Addition Name may. ` ' /dyF` Atotary ❑Jetted ❑Power Auger <br /> 6.DRILLING FLUID <br /> } 11+111 <br /> Block Number ' I 7.USE <br /> h� <br /> mes[ic flMonitoring ❑Heat Pump <br /> ' I,ot Number U Irrigation ❑Wublic ❑Industry <br /> f-mi. <br /> , ❑Test Well ❑Municipal ❑Commercial <br /> --t- i- - -r- I ❑Air Conditioning ❑ <br /> t , 1 <br /> F--1 mile, 8.CASING I HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address O Black ❑Threaded <br /> E <br /> tfEIGHT:Above/Below <br /> indicated above. dace (t. <br /> ❑Galy. ❑Welded <br /> Drive Shoe? Yes—No— <br /> Mastic ❑ <br /> lbs./ft. -4n. <br /> `_ ,�"„�:r�r"y✓� �in.to L�/ft. Weights ' <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to _ ' (t. Weight lbs./ft. }ten. tot. is <br /> FORMATION <br /> in.to ft. Weight lbs./ft. in. to t. <br /> 9.SCREEN Oropen hole <br /> from ft.to. ft. <br /> Make <br /> e <br /> Slot/Gauze s Length FIT INGS: <br /> ��� �r1/ Set between I rift.and�,j�ft. <br /> 10. STATIC WATER LEVEL / <br /> I04 <br /> _ft.D below ❑above Dale Measured y <br /> la urface <br /> n <br /> 11. PUMPING LEVEL(below land surface) <br /> ft.after hrs.pumping _ g.p.m. <br /> ft.after hrs.pumping g.p.m. <br /> 12.HEAD WELL COMPLETION <br /> gPitless adapter manufacturer-,tModel <br /> '.❑Basement,offset ❑At least 12"above ground <br /> ❑Plastic casing protection <br /> 13.WELL GROUTED? ;$Yes� ❑No <br /> Veal Cement ❑�Bentonite ❑ <br /> Grout material from to_ ft.cu.yds. <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAM{)AATION <br /> _C�Peet J direction g o type <br /> Or <br /> Well disinfected upon completion? JJQes ❑No <br /> ,y. <br /> 15. PUMP <br /> Date installed Cl Not installed <br /> Manufacturer's name <br /> Model number number C 1 'i !w7/I HPZ_Volts-) O <br /> Length of drop pipe U ft. Capacity g.p.m. <br /> Material of drop pipe `^< <br /> Type:9 Submersible ❑L.S.Turbine ❑Reciprocating <br /> ❑jet ❑Centrifugal ❑ <br /> 16. ABANDONED WELLS <br /> Unused well on property? ,JYes ❑No <br /> Use a second,heel,'J--h d wed Permanent ❑ Temporary ❑ Not scaled <br /> 1 17.REMARKS,ELEVATION,SOURCIrF 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. -} <br /> NOV Licensee Business Name ' License No. <br /> 2 5 2991 Address <br /> Signed y• �. Ld�-"�- Date ! J 1 •y/ <br /> Authorized Representative <br /> i <br /> Date) <br /> Name oJDriller <br /> T477429 /7430M <br /> 77/76 30M <br /> LOCAL COPYxE_o>Iios-os(xey.9/88) 7/7830M4 <br />