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_� � STATE OF MINNESOTA DEPARTMENT OF HEALTH �pL,l_;� <br /> - �_� ^ATION WATER WELL RECORD �N/NNESOTA UN/QUE WELL NO. ���Q O ^ <br /> � County Name �1 <br /> Jor Wate�Sample '' <br /> �.� Minnesota SNtules 156A.01�.08 L� <br /> Township Name� ���� ownship Number Range Number Section No. Fraction 4.WELL DEPTH(mmpleted) Date of Completion <br /> LUIM� I�C.}�. 11�/ ° �� �y �)s ,�� � ;=I�✓ 1 V� ��.�� ft. $"'l�T"�} <br /> Nu treet Add�ess and�' o ocation or Distance from Road Intersec[ion. 5. DRILLING METHOD <br /> 3�ui, �y;i� �Ggd� �}(�r �j,j��j� ��i3jb ❑Cable'lool ❑Reverse ❑Driven ❑Dug <br /> exact location of well in section i . Sketch map of well location. ❑Hollow Kod ❑Air ❑Bored p <br /> � � r i Addition Name s�Rotary OJetttd ❑Power�Auger <br /> -r -~ _1 _1 ���`���� 6. DRILLING FLUID <br /> i � <br /> 1 ' <br /> '-�- -=- i- �- Block Number ��� <br /> W ' � E 7. USE <br /> i <br /> _1_ _1_ _'_ S_ T ���.�T �mestic ❑Monitormg ❑Heal Pump <br /> � � i � . Lot Number O Irngation O Public ❑Industry <br /> f�m�. <br /> ' � � � � . ,- �� O Test Well {]Municipal ❑Commercial <br /> --�- �- - -r- � � � <br /> � � O Air Conditioning O <br /> �—1 mile� 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME HEIGHT:Above/Below <br /> Mailing Address if different[han property address ❑glack ❑Threaded <br /> indicated above. Surface ft. <br /> � �yr�r� �`�,� ❑Galv. ❑Welded .n+ <br /> Drive Shce? Yes_ No— <br /> .�1 pPlastic ❑ , J � <br /> `� in.to �'1+� (L Weight�Z�IbsJfL ��l�n. to%t. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to tt. Weight Ibslft. �n. [o-1t. <br /> FORMATION <br /> in.to ft. Weight IbsJft. �n. to�t. <br /> ��� �' ^t 9.SCREEN Or�open hole <br /> Make ��� (rom (t.to. ft. <br /> TYPe ��C�1111�.1�J J`t�i Dlam. (�fi <br /> SbVGauze �� Length <br /> �x <br /> FITTINGS: _ <br /> Set between�ft.and�tt. <br /> 10. STATIC WATER LEVEL <br /> �� f�below ❑above Da[e Measured �^"'��-'�9 <br /> land surface <br /> I I. PUMPIrNG LEVEL(below.land sur(ace) <br /> �`; tt.a(ter '' hrs.pumping �t' g. m. <br /> P <br /> (t.after hrs.pumping g.p.m. <br /> 12.yy�AD WELL COMPLETION <br /> �f'illess adapter manu(ast rer �� ���.'�.� Model <br /> 'O Basement o((set �t leasl 12"above ground <br /> ❑Plastic casing protection <br /> 13.WELL GROUTED? ,�Q Yes ❑No <br /> 13 Neat Cement ❑Bentonite L] <br /> Grou[material from,.LL�[o��tt.cu.yds. <br /> L7 \J t� CJ <br /> ' 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> / � � � <br /> , f., j (eet direction i <br /> YPQ <br /> � � I Well disinfected upon completion? �Yes ❑No <br /> 15. PUMP <br /> Date installed�`����7 ❑Not ins[alled <br /> ManufacWrer's name `� <br /> Model number HP � � Volts �'1� <br /> Length o(drop pipe ��, fL Capacity �2 g.p.m. <br /> p (�'� � <br /> Material of drop pipe � �'+�• <br /> Type: �ubmersible ❑L.S.Turbine L7 Reciprocating <br /> �OJet ❑Centrifugal C] <br /> 16. ABANDONED WELLS <br /> Unused well on property? f}Yes O No <br /> Use a semnd shee(,i/needed Sealed !�J''Permanent ❑ Temporary ❑ No[sealed <br /> 17. REMARKS,ELEVATION.SOURCE OF DATA,etc. <br /> • 18.WATER WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdic[ion and this report is true to[he best ot my <br /> knowledge and belief. <br /> ..�.�A�.9.A/1.�['► 1��i37.1L1 �iri3 W.r 1iR.. �7L <br /> LirenseeL�B'usineys,s,..N�.a�me y, 7 t,,ta..7�.., t�L,icense No. <br /> Address��•S�" liLQ119NG'.� W !t t'AL3'M,T� P2il• J�1J'F� <br /> Ci tW��"`'`r ;%�� ��..... ,F�' Date d�-�!�7-O J <br /> Authortzed Repre nse�tattue <br /> j11�.1�3c�i`2 Hltfi}l Date���''ag '. <br /> p Name oJ Drlller <br /> LOCAL COPY O O 5� O O 5/74 30M <br /> �i�s ao�n <br /> HE-01205-03 Rev.9/88) ��78� <br /> � 2ie2�oM <br />