Loading...
HomeMy WebLinkAboutwell info STATF�.OFMINNI-:S(IiA UF'.1'AItTMENT01 Hk:ALTH 1. L()l'ATI()N UI-WF�LL FIlNNFSOTA UN/QUF WE/.L NO. � O���� ' c���p��� WATER WELL RECORD � Min taSteN�esI3�A.!)I�.fIX T��wnsni�Name Tnwnsnip Numher Nen�c Numher Sec1���n N�. I�rec�i��n l. YROYF:RTV NERS NAMk: N o �a v. v. B�hG�iR �.�.�," °s`��i w `�J 5�1► 3M � ��i �l�.�4 ,_ I)Istance and ItHe<li��n h�rm HuaJ In�ersecliuns ii�Sircet AdJrns anJ C'i�Y of Wrll Lt�catiun Addr Sf �� �� � �� �� ....� ���� Snow eK�.�l l��c�lion o!well in aec�iun griJ wilh"X." Sks�cA ma0 of well loc�iion. a.W' l DEPTH(completed) Date of Comple�ion N ' AJJili�m Namc _ L _ _ i _ti - ft. i 5 1❑l'ahle li��i Neverse 7❑nriven 1001)ug M - � - -•- - - E . , , � bl�rck Numnn �;{ y 1�Hn11nwroJ s❑�„ aDe�,.<a ii0 � — - ' '— '` if�j,. �Ni�tary 6�lel�ed 9�Ynwer AuLer � , . � 1 Lol Num�er b. USE "i' ' __'_ _'i'__"_' �7n��mrsu< aOv�m��s�vv�r �O i�e�:«Y $ F--1 Rttt� 7Olrrlgali��n 5❑Municipal 8❑C'nmmercial 2. FOkMAT10NL0(: ('OLOH HAitl)Nl�SSOF fk()M TO IONMATIUN l�Tr�l Well 6❑Air('�rnAili��nin6 9� +�,� 7.CASING HEIGHT: Above(Below HOLE DIAM Li�3 �'� '� � I❑Black O�ThrcadeJ � �.��. ]0(:alv. S�Welded Surfact ft. �+�� �e.�y� �M fi� J(+�laStiC 6❑ ����Shoe? Ya_ No� �Y1' .�,_in.to ��fl. WeiBht �_ly�./ft. �In.to_ft. �a� � �� �� �K �n.lo f�. Weitht IM./ft. �n.lo_It. in.to fl. Wei¢ht Ibs.�ft. _in.to_ft. ���t � ��. �� a. s��� ,o,�� o�� Make from ft.fo h. Type�� Dia. � y ' �7 51�1/Gauz< r� Length F'ITTINGS: Se1 befween � ft.and �fl. f1.and f1. 9.STATIC WATtR LEVF;L j� ft.�helnw ❑ahove DateMeasured (*'!�" - ----- - land sur(ace � 10.YUMPING LF;V EL(below land surtace) . . ��� . (l.aher hn.pumpin8 B.p.m. fl.afler hrs.pumpinB 6.p.m. 11.WELLHEAUCOMYLF:TION .�,�,/�r�.�,.�� ��+�a. �Q Pi[less atlepter,manufacturer �Y2i.i��taiiiotlel z0 easemem orr:r� JO Al leaet 12"ebove�,ae - 12.WELL GROUTEDT L7ves �tlo i❑n<��c�m�•�� zOero����ur �❑ Groulmeterial from to f[..Cu.VEs. 13.NEAREST SOURCES OF PO6SIBLE CONTAMINAT[ON �feet direction Iype Well disinfected upon complet�on? Ves� N��❑ 14. PUMP Date in�IW� �� ❑Not installed ManufatfurelY Name �� ������ Model Number HHi`'�_Volts � Length of Arop pipe ��f ft.cap�cllY �j� B.p.m. M.��.�.i or e�ov v�ve 3�E���. Type: �Suhmcrsinle 3�L.S.Turbine 5❑Meclprz�cuting I�Jrt 0�C'rnlrifu6+1 6❑ Useasecondsheef.ifneeded �6.WATERwELLCONTRACTOR'SCERTIFICATION 15.REMARHS,ELEVATION.SOURCE OF DATA,ecc. This well was drilled under my jurisdiction and this reDort is true to the best of my knowledge and belief. ..�� '�'��l�i� ���.��i Littrtree Bu.rineu Name Llcenx No. �wa.ess��#4 ��.� �� ��'1�t' ��].i2�-� �""I.1'"'s�� .. . � Signed Date Aulhorix<d Represenlative rs�_'s. ___ _ __ Dete��„�� �o�a� C�PY 4 0 3 7 61 hN'""or orai« sna soM 7/76 30M 7/78 30M HE-o1205-0� 2/82 lOM