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HomeMy WebLinkAboutwell info titATF()F MINNF�.S()TA UF.YANTMl;NTOF HF:ALTH I. L()('ATI()N UI-wl LL MINNFSOTA UN/QUE WE/.L NO. M �.�� � c�����r N.��< W A 7 E R W E L L R E C 0 R 0 � Wa� Samp�� s� ��� � Minn raS�alutnlSnA.rll�.rlx - Y � !'i�wn�hip Name Tnwnship Numher Han�e Numher y�c��i�n Nn. I�r�it���n 3. YROYERTY OWNERS NAMk; t3�ras� I27�i 5� Z3i� W 33 n� '`se '` e�y P er�sse�- - �'�L-�-� IlislaniC an�It�Ke<I���n fr�rnl 12ir�J InterSecli��ns��r Slreel A�Jress anJ C'�IY o!Wtll Lncal�un AAdreii� �yr�'1'��Zr��.�� �� ����I M� It riiii _ ��e,-� -g53S� Sn�iw eu��I��ca�iun nf well in.ecil��n griJ wi�h��%." Ske�ch map of well loca�iun. 0.WlLL DEPTH(completed) Date of ComD�elan N ��� -L ' ' ` - AJJ�lii�n Name xw�'�7 ' - " fl. � � � 5. W -' ' ''' -I' - r 1�('ahlel����l 9❑Heverse 'I�nriven IO�i)u� i � + i � bl��ck Numhet y 7OHiNInwrv�J SOAIr 8❑Bnred II❑ ' - '- '� 1}Illj,. �Il��t�rY 6❑Jelled 9�Ynwer Auier I ' ' I I,ol NumAer 6. USE '_L "''' __ _"_'__ � 1 I�/nmexlic a❑YuAlic SupplY 7�Induslry S �—1"nU zOtr,ce+�+��n sOntun c�o+i m�rc eOc�m �.i 1. FORMATIONLO(: ��p�pH H�NIINF:SSOt F�HOM TO , t()NMATIUN J�irs�Wrll 6❑Air('��nAili�inin� 9❑ ].CASING H61GHT: ADove/Below HOLE DIAM �R� e��� i..4�..5,. !'�i � I�tllack 0❑ThreadeJ 1 av #ri�.l:tC. �! x�G�lv. 5❑welded Surface fl. ���p 4�j� � �� �❑Plastic 6❑ a��e Shoe? YG_ No d_ + � in.to ��� ft. WeiBht ��y� Ib�./ft. �In.�h. �rl$�I �31� 3� 37 ��.�o rc. w��sn� ma./e. —��.�o_rc 5 in.to It. WliRht IM./(I. _in.f0_h. C��$�� YIFY�b�, �� �Z B. SCRE�„��' ropen ole IYQMi� from f[.t0 ft. Ly /�� �^ ab ��j�-_'�+ $a. VJL F7� TYP� �JCt �L� Dia. � f SI�I/Gauxe - �� � Lmgih ^� ''�'}; '�''j� F'ITTINGS: ,�y�t,� �� � ��� Se�6etween �fj (t.and j�f1. Sf1R1a . � t1.and !t. .,��t� �1 ♦ L� �fs� 1� 9.STATIC WATF;R LEVEL iii�i�'���i �i'�"'it IO LY� 9� .. n�ei�,w ❑ano�e o,��Me.auree ���� • ..-- -- - lands'udace ��������� ��� S jy�] T�� 10.PUMYING Lk:VlL(below land wrface) �� i�ll � (t.ah<r Ors.pumpin6 8.p.m. ft.afler hrs.pumping g.p.m. 11.WF;LLHEAUCOMYLETION _ — � n s � iC.�+��esseaapie.ma��ra�wrer ,,,odei . „ � i` ��� L� \ � I�Basement of(scl �AL least 12"ebove grade - � _S - -"� �� 12.WELLGROUTED? �kc ❑No .. . . — I�l`al('emcnt 2❑B<n���niie 3❑ Grout material from ft..Cu.VAs. ` �� t �-. -'"'�� 13.NEAREST 80URCE6 OF POBSIHLE CONTAMINATION � ""� ��feet direction lype Weil disinfecfed upon complel�on^. Ves�' Nn❑ 14. PUMP Daee in:ull<A ❑Not installeA ManufacluretY Name �� 'gr� l Mod<INumber HY � Volts� Length of drop piDe � � (t.cap�city�� g.p.m. Materinl of drop pipe �F� Tyve: i�unmcrsinir ��L.S.Tulbine s❑Heclpn�caling 301rf 4�C'rnlrifueal 60 Useaseconasheat.ilneedad �6.wATERWELLCONTRACTOR'SCERTIFICATION 4RKS,ELEVA170N,SOURCE OF DATA,etc. This well was drilled unAer my jurisdiction�nd thi:repon is�rue�o the best of my knowledge and Eeliel. �tt3Ye�S �Tla,21 C0 �1.91a Liceluee Builneu Name Llcrose Na. ,,�� bz�� � �.� �r,��,z� ��, � --......_. ____ ._� :, Si{�ed � � - Date 1'�y Y2/ Aulhorized Represen�alive , �.$ ��YS u.c�l—�f—�� R.'�,.+"«PRL C\.'�� ..y' .{ � �j +`�� NameofDrdlet 5/7d 30M 7/76 30M J '�-'�- 'a%��t .'-� �--- 7/78 30M HE�01205-01 2/82 10M