Loading...
HomeMy WebLinkAboutwell info STATt Ok�MINNI�:S()TA UE'.YANTMF:NT OI�Nk:ALTH I L(�l ATI()N UI WF LL FI/NNFSOiA UN/QUF.WEI.L NO. ������r����••�/� WATERWELLRECORO ,w„osomk �� tl �� � '� ' ����^��A . Min eaSralurnlSlrA.rll..r1M ,n v a�r �S` ��" T�iwnshlp Nnme Tnw�sh�p Numher Nan{c Num�er $�cilnn Nn. I�raiti��n 3. YROYk;RTY OWNF:R'S NAMF; r�r��Q Z�� �Sr '^"./ b W �� .�i%.i 47� at� s+3f'�i��7. .Ju:��i� '..._...... - . I)Islance+nd Ilkeclum trum N�u�Intersecli��ns��r Slrcel AJJress and C'lly of W�II Loc�liun Addra6t � "�"h� � ,Rw?.Q` �2l�QIC�@2'�'�f T'f 1(.-\..- `\� _ SM.w ea�c�I��crc�an of well in vec�iun rriJ wi�h"%." Sketch map of weil Incation. 4.'.V1kLL➢6Ei'H wn '� : N tc v�e�ea} ...�___. . .... . o.unrcomp�.��o� , :� AJJili��n Name '�%i J ,i��I.�•L 3 G V' ���+.t"'a..� r _L_ _ _ ' `_ _ _ h. � � � 5. N -- - �- -I- - E iOc�ni<����d oOe�..� �❑n,�.�o io�n�e i i { � tll��ck Num�tt ` EOyHollnwrnJ s❑�o- sOe��ed ii❑ � _ - ' '- _� �� 7i-1 H"�'rY b❑letted 9�Ynwer Au`er ' ' ' � � Lot Numher 6. USE '_i_ ' __'_ _ ''_'__ �y iL7o��mr���� a❑v�nu�s�vv�r ��i�e�:�ry $ r-1 miis 2Otr,cg�r��� sOnw��c�p,i eOc�mmr,c�,i l. kORMATIONLO(: ��n�nµ HAHItNh:SSOt FH�M TO F�()NMATIUN l�Tr��Wrll 6OAir('i�ndili�nin� 9❑ 7.CASING HEICHT:AEove/Below HOLE DIAM �'��..'�I7il '..+Z�,� ��'�f�13 ..i:3�t � s��. �mui��k aC�nrr,a<a iOc,i�. s❑wetara s��r,« n. v�t�� Z.t�� ..�Q�ir Ga �VG7 l�PlastiC p❑ DriveShoe? Y<�_ No_ L �m.ro ��� !t. WeiQht Iba./fl. -fn.to_ft. 1.�.$�' � FiIY'1+� �,€Z'"b� x rL7��+ i�V 1� ��.w n. we�ene ms.�r�. —�o.�o_tt. �n.[o tt. wef¢n� �b:./R. _+n.�o_ft. `:�.;'.'? ��z?"+'1:�i7; .�u4'�� 1� �.� e m���Nai C1�2A�iQl1 r.om�� m� n.�o r�. �ta�nl�ss �steel � TYP� Dia. Slot/Geuze � � a Len th "� � 8 F7TTINGS: Setbetween n.,�a (1. n.a�a n. ,3 �:'�s �'�'��'fiA:-:�f3i1 9.STATIC WATk:R LEVEL '_ __ _ "-"� (I.�trel��w ❑ahove Dale Measured ` �� land surfatt lo. YUMYINGLF;VEL(belowlanJsurface) �j fl.aller hrs.Oumpin6 '"� g.p.m. ft.af�er hrs.pumPin6 B.p.m. II.WF:LLHk;AUCOMVLtT10N ��itless adspter,manufac[urer model z❑eas�m��i orrsr� �O ei ie.s��z�� ..e g.me 12.WELLGROUTED? �- I_.JRe� ❑No I�Neal('emcnt 2�nt�inite 3❑ Grnut materiel fr�m ft..Cu.YCs. 13.NEAREST 60URCES OF POSSIBLE CONTAMINATION feet directlon type Well disinfected upon comple[�on? Yes� Nn❑ 10. PUMP Dale instslled ❑Not fns[slled h@tx'�'�.(iT' Manu(sc�ureiY Name J � Model Number HP � �I� Length of drop pipe ��ryft.capacitY B.p.m. :.�LCB.E Material o!,.dyroD D�O� .. . 7ype: IL'T'Sunmcrslhlr 7❑L.S.Turbine s❑Reclpn�cnting l�lel <�C'<ntri(uWl 6❑ Use a secrond sheet,il needed �6.WATEH wELL CONTRACTOR'S CERTIFICATION I5.REMARKS.ELEVA170N,SOURCE OF DATA.ecc. This well was driiled under my jurisdiclion and Ihis report ia true lo the best of my knowleOge and belief. i�llk :.�U�lAel" �El1�. 4.0. 1���.�� � Litrnare Buainru Name Llcerue No. ,�ee,�x `tJX �.��• �"�.0 wCaT��• P� 1�����i — : ,� :�,/�;e'`f ' `,��� ,�r,+/�.�,� 4 Sg d l�,���� ��_. � J .� '�Date � � Authorixed Reprcsenlative - a�xttl7t"�[Sa i._ �.a��l�e�sw ua�e K/R/��l �.:�:r�L ���Y � N.m�o�o���a ,•`, �•" ° ., k',��„ 5l74 30M - 7/76 30M , _ _... ..,�. �..'" 7/78 30M HE-0120.5-01 2/82 10M