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HomeMy WebLinkAboutwell info STATM.()h MINNI:S()TA UF�.1'AN7MF;NT OI�IIF:ALTN I. l.(1('ATI()N UI-WF�LL M/NNFSOTA UNlQUF WEl.L NO. c�����rN.�,< WATERWELLRECORO 40376� � ro,wure.sumplr Minneso(o StaNte+/ShA.l1l�.flN T��wns��p Nam< Tnwnship Numher Han�c Numher yccli��n N�. I�ra�tli�n l. YROYlRTY OWNF:R5 NAMk: N � E �. Y. / � . �� Sr W '�� . I)istani�and I�wec�iun frum HouJ Inlrrxcti��n�ur 5�rce�AJJress anJ('��Y of W�II I.oc��ion Address '2� Py��w}�.� 7�►b�Ri.#ili� t� � �; �'�`�! 5n�iw ea.�t li�ca�iun o(well in ucllun priJ wilh"X." Ske1cA map o!w<II loc��iun. 4. 'LL DEPTH(completed) Dale of Compl<tion � AJJ�I���n Name ����, _ �_ _ N . _ _�� n. � i - i - - I-- 5'iOc.niri����i oOk��r... i�n,�.�� io0o�` N -� - -'- -+-I - G Nl�ick Numhe' Z�HnllnwruJ S�AIr B�Bored I I❑ ' - - '--_� �ML. )O N"��rY 6Oleifed 9❑Ynwrr Auger ' � ' � � Lo�Num�er 6. USE 'i_ ' __'' __ _'_•'_ �Ih�meslic a❑YuAlic SuDD�Y 7�Indus�ry � F--1�II.tI� Z�Irrigalinn 5❑Municipal B�C'nmmer<ial 3. FORMATION LO(: ('OLON MANI)Nh:5501� F�µOM TO !()NMATIUN J❑Te�t Well 60Air('i�nCilionin� 9❑ 7. CASING HF:IGHT: Abov</Below HOLE DIAM � �� l�,.�. � 1❑Black 4�Threadrd �.i' 2❑Galv. 5❑WelAed Sur(ace (t. Y�� �2� � '}� �PI85tiC y❑ Drive Shoe? Ve�_ No� 14F�` ;� �{��Q � �n.to �� ft. Weighf ��l�� Ibf.(ft. In.}di7.j—ft. �:� �� �y �Sy in.to ft. Weitht IAs./ft. —n.to_ft. �n.to h. WeiRht Ibs./!1. _In.�o_ft. ����Y�p w1 id�R �� �j� B.SCRElN r open ole .w.,1��V 1Y.iRi� 7 � Make hom !t.to tl. �3r�a �p �a�r �1 7� TYo� � o�.. � SI�tfGauz< �� Lengfh � �+J�'g� i�ITTINGS: ♦ _� a � wA ��_"' Selbelween � (�.an0 .j�j,�,_fl. afF �61Rf�1Mi�rY �qP K fl.and f[. 9.STATIC WATk:R LEVE:L � ft.Ohel��w Oahove Dale Measured�w�� — - -"— — ' land surfice 10.PUMPINGLk;VE(,(telowlandsurface) (1.afler hrs.pumpin6 �� B�D�m� � — fl.afler hrs.pum0in6 6.p.m. � — _— II.WtLLHlAUCOMYLETION � �yyy,p�.[`.�� � �.MR�p �❑Pitless atlapter,manufacturer� moael z0 ua:er�eni ornr� �O ni ieas�iz'�eto�e a�=ae 12.WELL GROUTED? ❑Yea liNo — 1❑Nea�('emcnl I❑Benf�inite J❑ Grout material (rom t�� ft..Cu.Yds. 13.NEAREST 60URCES OF PO65IHLE CONTAMINATION �_feet dirc<tion �ype Welt disinfected uDon complel�on? V<'Q Nn❑ 14. PUMP Date insUllcd ��� ❑No�fns�alleC ManufecturefYName ��� �� Model Number NP�Volt���t ��' Length of droD Dipe �4��_ f�.cap�citY Z�_e.p.m. Material of dro0 p�pe �,�'� Tyve: �Suhmcrcinlr ���L.S.Turbine S�Neclpnrcat�ng 2�1e1 <�('enlri(ugil 6❑ Use a second sheet,if needed I6.WATER wELL CONTRACTOR'S CERTIFICATION I5.REMARKS.ELEVATION,SOURCE OF DATA,etc. This well was drilled urtder my jurisdiction and thi:reporl is true to t�e besl of my knowledpe and belief. $�� ���.� �i �t��:�f Licensn Burineii Nnme Licrnx No. ,,�.�u b2$� �r 1.� �, :`;�g� �l.a�x� �.� �` � SiBned Date ����~� Aulhotized Represenlative �C�{� i tBY�t� �"'����t : Drte Name o(Dnller 403760 snoaoM LOCAL COPY ���6�M �nesoM HE-o12o5-ot 2/82 tOM