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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CounryName WELL RECORD � $� 7 8 � <br /> Hennepin Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion <br /> n. <br /> ��. ��, ��. 4 6 2 2 <br /> Numerical Street Address or Fire Number and City of Well Location DRILLING METHOD <br /> f� �t1T I Cable Tool Driven � Dug � <br /> �'+tJ varrett ��r�nue. Wa Za� 1'3i1• i.; Auger �.� Rotary .-�: Jetted <br /> Show exact location of well in section grid with"X"./t� _! Sketch map of well location. ..� <br /> l,J r�f'�� Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> I � � i , � <br /> _'r_ �_ _1 -1_ �3@13tt7li.t��> <br /> i � <br /> i i i , USE <br /> W i � � E �!�' �I Domestic - Monitoring `� Heating/Cooling <br /> � [' Irrigation � Public � Industry/Commercial <br /> -�- -i- -; =- T � �.�� t� �;� C Test Well � Dewatering l <br /> , i ' <br /> , � , <br /> f"m' CASING Drive Shoe? r Yes �'No HOLE DIAM. <br /> '-�- �- - -r" � ❑ Steel LJ Threaded f 7 Welded <br /> i � <br /> 1----I»+i1e,—� L E.'` � Plastic ❑ <br /> � `: <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME l�in.to_1�ft. I�g ibs.in. �33�;�,ro����g�' tt. <br /> � I, ,� a in.to ft. Ibs./ft. ��►,tqt<xr ft. <br /> Mailing address if different than property address indicated above. in.to ft. Ibs.ttt. in.to ft. <br /> SCREEN OPEN HOLE <br /> 54�3 Barreti Avenue Make ,Tc1�1it�30ri trom�ft.to tt. <br /> Type stainles� �i�.�L�. Diam. <br /> W$�zata� ?+�N 55391 SIoVGauze 2tl Length 4—ft. <br /> Set between 3�,� ft.and��ft. FITTINGS: <br /> STATIC WATER LEVEL p <br /> FORMATION LOG COLOR HARDNESS OF FROM TO O1 ft. .�8.below ; above land surface Date measured � 2 �2 <br /> FORMATION <br /> PUMPING LEVEL(below land suAace) <br /> �i18 brown 1S�C1 Q I�} 1� ft. after 6 hrs.pumping �'� q.p.m. <br /> WELL HEAD COMPLETION <br />� � �� ?� �iPitlessadaptermanufacturer,.�l�t�4f$t@T' Model ��t• <br /> 1 Casing Protection <br /> � GROUTING INFORMATION <br /> Well grouted? �}l Yes G No <br /> Grout Material �'}�Neat cement�Bentonite <br /> tt1C��t Cp�^�-,-'��lt from��S��. to�tt. yds. 'J bags <br /> [�IItOt11t� from JL to iJV ft. ��yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST SOURCE OF POSSIBLE CONTAMINATION <br /> 5� feet I]flI�11 direction SE"p�iC type <br /> Well disinfected upon completion? T� Yes ❑ No <br /> PUMP <br /> f�Not installed Date installed �f 3 j9� <br /> Manufacturer's name l��rc <br /> Modelnumber�3tQT'g HP 31�_Vol[s <br /> Length of drop pipe �l6 ft. Capaciry�� p.m. <br /> Pressure Tank Capacity <br /> Type:,� Submersible � L.S.Turbine 'J Reciprocating ❑ Jet C <br /> ABANDONED WELLS <br /> Not in use and not sealed well on property? ❑ Yes ��[lo <br /> WELL CONTRACTOR CERTIfICATION <br /> This well was drilled under my jurisdication and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Useaseaondsheeti�needed Bergerson--i:aswell. �iAC. �7.�'J�`� <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. <br /> � ' � ' 7�2�9� � <br /> Authorized RepreSentative$�ganture Date <br /> ��TZ'1S SCtfUZt2 7�2��2 <br /> Name olOnller Date f <br /> �OCAL COPY �# C.1 � (j � � ME-01205-03(Rev.9/91) <br />