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HomeMy WebLinkAboutwell info STATF�.()4 MINNF:S()TA Ok'.YARiMlNTOI�NtALiH I. Lnl'AlI()N()I�H'h:LL F/lNNFSOTA UNIQUE WE/.L NO. ,� _., � � � � c„���r��,p�,.y•��� p W A T E R W E L L fl E C O R D ��,war�.samo�e � �j- � �A r .m� �� '�VF4ii�G4��X4 Minnriora Srenlrrf/SM1A.111�.11x �� �� I'��wnshi�Name Towns�ip Numher Nan�e N�mher y�c�inn Nn. 1 r��clii�n J. YROYF:RTV OWNF:RS NAMF: . ( , N E .. / 4. �,:+Y'filKJ ��.�1 �` S` .�.3.� �'H` � iit�i r9.� :.rfd i:.� '. � I)islani�and 1>kecli��n frum H�uJ In�ersec�i��ns�ir SIrce1 A�Jress anJ C'ily of Well Loc�liun AddreTf,�� � f ';.:Z'�Ef�"1eV :. ��CB � u7.'c?� Snow ec�c�I�rc�tion of well ln ttcliun Bri�wilh"%." Skelth map of well l�xatiun. 0.WF;LL DEPTH(completed) D�le of Completion N ,-�,-, ' �r ' AJJilii�n Name . �:'�.� _ L _ _ � '_ti. _ �� ft. ��-i,r.� w.:.� . � � � s iOc.nir�����i aOH�.e� o❑rn�.e� �o❑o�e M - • - -�- -+-I- , - E u,,Kk n�m�n y z❑H,m��w,��u s❑n�� eOa�,ed n❑ —�� '' —� i}�11.. J�H��t+rY 6❑Ieited 9�Yower AuQer I � ' � � Lo�Num�er b. USE "i_ ' __' _' ___,_' iQ�lrn,mr�n� a❑v�nu�soovir ��i�a�:vr $ �-1 nII:U 2❑Irrigulinn S�Municipai B❑Cmmmereial l. kONMATIONLO(i ('OIOH H�HItNt:SSOF F�µOM TO IONMATIUN JOText Well 6OAir('��ndifiunin� 9� ]�.�C/ASING HEIGHT:AAove/Below HOLE DIAM .[���Q'� u�:;E.� �y�x� y�j�'� 4! �� If.JMack t��readeJ •c V 2�(;alv. 5❑Welded Sur(ace ft. ���� `��`�.� j�p ��� ,�� �� J�PI25tIC 60 Drive Shx! Ye�_ No_ _"',r 4 �n.to � ft. Weighl Ibf./h. —In.lo_f�. -'?,�.II� � C�?7.� �3�1a1T1 ;:3Cl�. �1� �� ��.�� «. we�em ins.�r�. —�n.�o_tc. ��.�o n. w��■n� i�.m. _i�.�o_rc. �y Q,� � 8. SCRk:lN��n� ropen ole til%-F�� U����l r.'.Q�� W �' Make �f �rom h.to ft. EiLs3.�.T1�.8'�i$ 8'��f3�. �: Type Dia. � � • Slot JGau ze Length F'ITTINGS: Setbefween h.and (�. n.a�e n. ' t'�.a 'v'�t.'fTYi".a i J!� 9. STATIC WATk;R LEVE:L �„ Y.�j� �jI� 9 ft.�helnw ❑ahove DaleMnsured •r�/ — --- — land Surface 10. PUMNINGLlVEL(belowlanAsurface) fi.afier hn.pumpi^6 � 6�F�m• h.aher hrs.pumping g.p.m. 11.Wk;LLHEAUCOMPLF:TION ��Pitless edap[er.menufecturer moAel 2�eas� em orrsn �O/+�leut 12"above gretle — 12.WELL6ROUTED? I.J�fe� ❑No — — I❑Neul('emen[ $U�enli�nile 30 Grout meter�nl from ft..Cu.Yds. _ l3.NEAREST SOURCE6 OF POSSIHLE CONTAMINATION � � � feet direclion type r � � r � ��--,.� �( � � � � � Welldisinfecfeduponcomplel�on". Ves'L'7 Nii❑ 5. 10. PUMP i ! �� !3R`'-�� Dale instilled ❑No�inslalled ±��� ManutacturetYName ;:ytm�����` 4�Z. � ModelNum�er . HP�Volls t„ Lengih of dro0 Cipe (t.capaci�Y B.p.m. � �� Material of,ydrop p�pe Tyve: IL�TSunmersinle ��L.S.Turbine s�keclpn�catinQ 2�)rl <QC'enlrifugdl 6� Use a second sheet,it needed �6.WATEH WELL CONTRACTOR'S CERTIFICATION 15.REMARKS,ELEVATION,SOURCE OF DATA,etc. This well was drilled unEer my jurisdiclion�nO t�it report is Irue to �he best o(my knowledge and beliel. i.:s?tl'�3�1!'�.' ���.� ti4• �()�e:� -- � Lieeruee Businai Name Llcenn No. _ „�,n., :�Qx 159. Yictcrirq►. s�n 553#�a .. �� Si6ned �����i6�/ ��.G/�...��Dafe __— Auth�ed Repruentative .n2111F;�i ,.E�iP�'�.E?� n.« � � �! 5/ Name of Driller �.,..✓'�,5-c� �<�J�.1 � y '�°�� 5/7430M , R�� 7/76 30M .. .».e,. 7/78 30M HE-01205-Ot 2/82 10M