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HomeMy WebLinkAboutwell info STATF OF�MINNI':5()TA UF'.YANTMF:NT OI-HlALTH I. L(�l'ATI()N()I�WI�LL F//NNFSOTA UN/QUF WE/.L NO. ������rN+�� WATER WELL RECORD '� � � ��� :j � � JorWarcrSample L`-� . Minnttora SreNfel fShA.lil-.IiX T�iw�c�ip Name Tnwnship Numher Nan�e Numher S�c�l�n N�. I�ra�'ll�in 3. YRONF;RTY OWNER'S NAMt N E ; �, y, m or ., 1)isi+nce and I)� tliun frum NoaJ Intrrucli��ns��r S�ree1 AJJress anJ('lly o!Well Lnc�iu� Add st������ ��/�� G � � ��ii/Yi1A+l _.'"X"!�i'-'.—.—_" Snnw ea�c1 I��cation o(well in.ec�iun griJ wilh"%." S�e�ch map ot w<Il incation. a.WtLL DEPTH(completed) Date of Completion N _L' _ ' _`_'_ " AJJilii�n Name ft. .� � � � 5. ,. _ . i i � r iOc.niri��oi a❑k�.<.x oOn��.�� �oOo�e e. M -' - _ _ _+_�' _ L bl��ck Numher 2❑HnllnwroJ S�Air B�B�red 11❑ ' - - '- -� 1S�Rj,. l❑1lF�IatY 6�lelted 9❑►�wet Au`er _ " ' _ ' � Lol Numl+et 6. USE � "1_ _ _� " ' '_ __ i[Yi���m«u< a❑v�n��o s�av�r �O i�a�.vy $ �—1�� 301rrie+li��n 5❑MuniciDal e�C'nmmcrcial 3. FORMATION LO(: �'OLOIt H�HI)Nh:S50F F'HUM TO k()NMATIUN l�Trst Well 6❑Air('nn0i�ionin6 9❑ l.CASING HEIGHT:Above/Below HOLE UTAM ey)��,�1 �4+_q' � � IDBlack 4❑ThrcadrJ L iA .i�.46 iOc.i�N s❑weieed s�rrace tt. �i�{atis• w,m'�� � �C ��PlastiC ��,� Drive Shoe? Ya_ No ^�_ �r� ��a f.�.7 (�,, � in.to �� ff. Weig�t� ��'� Ibf./ft. �7{n.to��. ��� �����. � �� ' in.lo fl. Weight I�s./fl. —in.to_(t. . n.lo ft. WeiRh� Ibs./ft. �n.fo_(t. +�� � � � e.SCRF:lN ��Jy� r open ole � MakC ����i��/� - (rom f1.io (I. - TYFe �� Dia. 1S�"$��� �l�"" �� �� �„'�`{} tJ� si�yc,�:< ���ern FITTINGS: ..���L +��e� Se�belween �� f�.anA �� (�. � i�"'i7 93 idlG ,. n.a�a n. 9.STATIC WATER LEVEL ��� ��� ii.� J..7L �Li n.C'�ri��w ❑�n��< oa��rnee:�.eAL�ii'� i -- — land wrface 10.PUMYINGLtVEL(belowlandsur(ace) � � �� �� (t.afler hrs.0umpin6 iu{/ B.p.m. f�.a(tet hrs.pumpin6 6.p.m. 11.WELIHk;AUCOMNLk:TION �[�'itless edap[er.manutacturer model z�aa: ����rrsri J�At leest l2"above grade 12.WELL GROUTED? lJies ❑No I�a�C'emi•nl 3�Benl��nile 3❑ Grout meteriel from to ft..Cu.Yds. � 13.NEAREST SOURCES OF P06SIBLE CONTAMINATION �feel direction type W<II disinfecled upon complef�on? Yes'�' Nn❑ 14. PUMP Date instalkA ❑Not installed Manufac�ureiYName ��� MoQel Number HP�_Volts z,��, LengthofdroppiDe ,.,�_ fl.capacitY ��_e.p.m. Materiei of dro0 p�pe � Type: I�yuuhmcrsiMr 3�L.S.Tufbine S�Reclprnteling A 7❑lel <�C'enlrifugal 6� Useasecrondsheet,ifneeded �6.WATEHWELLCONTRACTOR'SCERTIFICATION I5.REMARKS.ELEVATION,SOURCE OF DATA.em. 'fhis well was drilled unAer my jurisdiction and this repon u true lo the best of my knowledge and belief. � icenrer ustniu Namr Llcenx No. ! � 4�`��`� '� � � „�.�„ fi?�1 H�► � �, �p1e PY,a�a, � � _ -- � .. ,.____..�._._—t .�. : ,,,_,.s.,�,�..>-w - � , t. ,{,� .. �,.. . � "1 Y Si6n<d ln,.s3-.. .� D�te�� 4 � . . , . " Aufhorized Represenlaliv< ��C� �►'�ii@tTtB n.te �"�•-ri—.f��i e'�di.+-\L COP� ` '� f��� ' NameofDriller 5/74 30M ... ' 7/76 30M -. .� _ .�• ..• 7/78 30M HEA12o5-Ol 2/82 10M