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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELL RECORDSEP 2 8 1994 5 4 6 017 �
Minnesota Statutes Chapter1031 `
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Township Name Township Na � Range No. Section No. Fraction WELL DEPTH(comple��.��'i. . � ' ork Completed
n.
118 23 � . �. 167' b/28/94
Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Dug
❑ Auger ['�(Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑ '
Showing property lines,
N roads and buildings. DRILLING FLUID �
' ' -� -1- Bentonite
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i � � i� .USE ❑ Heating/Cooling
._+_ ___ �_ � omestic ❑ Monitoring
� � ❑ Indust /Commercial
yy � i � E Irrigation ❑ Public ry
' T ❑ Test Well ❑ Dewatering � Remedial
-J- -?- -- =- � ❑
I � '
� r-mi. CASING Drive Shoe? ❑ Yes C�Jo HOLE DIAM.
� '
";' �' - -�' j ❑ Steel ❑ Threaded ❑ Welded
�plastic ❑
�1 milr-� 7��
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME _�_in.ro��ft. Ibsltt. �i�,��.C I g.
��� in.to ft. Ibs./ft. in.to ft.
Mailing address if ditterent than property address indicated above. in.to tt. Ibs./ft. in.to ft.
467� Creekvood Trail SCREEN OPEN HOLE
Make�, from ft.to tt.
iKaple Plain, MN 55359 Type te1 eoscopin� Diam.
SIoVGauze i c7 Length S�
Set between �62� ft.and 157 ft. FITTINGS:
HARDNESS OF STATIC WATER LEVEL
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 71 ft.qQ below ❑ above land surface Date measured 6 28 g
PUMPING LEVEL(below land surface)
clay yeilow � 17 ft. after hrs.pumping 10� g.p.m.
WELL HEAD COMPLETION
L•la �rep 1'1 1'14 ❑ Pitlessadaptermanufacturer Model
i
❑ Casing Protection ❑ 12 in.above grade
�and b gravel �ed y y� 1 35 GROUTING INFORMATION
Well grouted? ❑ Yes ❑ No
Grout Material ❑ Neat cement ❑ Benronite
C13 r2d 135 149 from to e. ❑ ya5. ❑ bags
from to ft. ❑ yds. ❑ bags
ravel mixed 149 167 from �o n. ❑ Yas. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
feet direction type
Well disinfected upon completion? ❑ Yes ❑ No
PUMP
❑ Notinstalled Dateinstalled 8/29/94
Manufacturer's name MQ e=S
Model number HP Vof[s� �
Length of drop pipe ft. Capacity L g.p.m.
Pressure Tank Capacity �a0 qa 1•
Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
- Does property have any not in use and not sealed well(s)? ❑ Yes �No
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Useasecondsheet,i/needed �tr@'V�I18 Driiling b BI1Y• 86654
REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.orReg.No.
, _..
�, . _._fi/28/94
Authorized Representative Signature Date
Paul Swearingen 5/28/94
Name of Driller Date
L�CAL CC7PY 5 4 6 017 HE-01205-04(Rev.5/92)