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1.LOCATION OF WEMI County WATER WELL RECORD MINNESOTA UNIQUE WELL NO. 434017 <br /> I /� O 1�] <br /> Cnty Name <br /> Miwwem/a SfwJrfq .w Wile►Sewrpls L} L{ 1 <br /> 156A.01-.08 r <br /> ownshnp Name, ownsh,p Numbswange Number Section No. I Fraction 4.WELL DEPTh,completedl Date of Compktor <br /> 117 '4 or 37 <br /> Distance and Director from Road Interswiian or Street Address and City of Well Location 5.DRILLING METHOD <br /> 10 Cable tool 413 Reverse 70 Driven 100 Dug <br /> Show exact location of well in section grid with"X." Sketch map of well location. 20 Hollow rod 50 Air 80 Bored 110 <br /> N <br /> 1 , Addition Name 30 Rotary 60 Jetted 90 Power iauger <br /> 6.DRILLING FLUID,., <br /> :,et tont <br /> ._�_ _1_ �_ �_ <br /> Block umber <br /> W , t E 7. USE <br /> fM Domestic 40 Monitoring 80 Heat Pump <br /> 1 T Lot Number 20 Irrigation 50 Public 90 Industry <br /> If mi. <br /> n 30 Test Well 60 Municipal IOD Commercial <br /> 7O Air Conditioning 110 <br /> 1 mile 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME _ r 10 Black 40 Threaded HEIGHT:Abryre/Bebw <br /> 1-77 <br /> ptCl!rOr=tel `• 20 Galy. SO WeldedSurface tt. <br /> <:: � L. [ Drive Shoe? Yes_No <br /> Address -30 Plastic 60 =� �: <br /> d <br /> in.to 125 ft. Weight - ' IbsJft. - -;n. J-2 It <br /> 3. FORMATION LOG COLOR HARDNESS Of <br /> FORMATION FROM TO in.to Wi <br /> ft. Weight lbs./ft. n. to--Jt, <br /> in.to ft. Weight lbs./ft. in. to---Jt <br /> •.,�E7 ..r! �r e -�� 9.SCREENS Or openhok <br /> r� Make .J�3�'il1I3E}a'2. from rt.to. ft. <br /> race .`� -3 Type t2'iu3�35 �Lwe Dis... <br /> Slot/Gauze `J :� Qt Le 1 Z <br /> ravel .est -v Set between 3`•5 ft.and 130 ft. r S :, C�$f��`-i INGS: <br /> f 10.STATICrWATER LEVEL <br /> ♦' i <br /> .� v :•rave l ---ray '�`� 1J3 a ft.Obelow Oabove Date Measured <br /> land surface <br /> ^^ :t 7 11. PUMPING LEVEL(below land surfatt) <br /> • ZI <br /> ft.after firs.pumping 9.p-m. <br /> ft.after hrs.pumping g.p.m. <br /> ravel �.Tlrne Lact _.. >t :30 12.HEAD WELL COMPLETION <br /> 10 Pitless adapter.manufacturer model <br /> 20 Basement offset 30 At&east 12"above ground <br /> 40 Plastic casing protection <br /> 13.WELL GROUTED? <br /> ZYes O No <br /> K]Neat Cement ?0 Bentonite 30 <br /> Grout materialy�� from to 7 .ft.cu.y�l�..._..,.__ <br /> -iGSi lfY�'�Lw sir ..� �.".✓ <br /> 10__CL �• <br /> :a.ii hili •e D— I 7 •I rS: • <br /> 14. NEAREST SOURCES'3 °3 OF POSSIBLE CONTAMINATION <br /> 3 '.ter ^>" <br /> feet �� direction type <br /> Well disinfected upon completion? :]Yes 0 No <br /> 15.PUMP - <br /> r=1 t7 <br /> Date installed O Not installed <br /> Manufacturer's name <br /> r e� <br /> Model number HP ca Volts_-^-'' <br /> IVLength of drop pipe �� i ft. <br /> ,.i capacity �b g.p.m. <br /> Material of drop pipe i.-il t nizeds <br /> Type:tG)Submersible 30 L.S.Turbine 50 Reciprocating <br /> 20 jet 40 Centrifugal 60 <br /> 16. EXISTING WELLS <br /> Unused well to property? O Yes O No <br /> Use a second shed.i/weeded Abandoned O Permanent O Temporary 0 Not sealed <br /> 17.REMARKS.ELEVATION,SOURCE OF DATA,etc. <br /> 18.WATER WELL CONTRACTORS CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. t 715 <br /> Lwswree Bwsiwess Nowa License No. <br /> Address 511! <br /> i Itmt Imple l <br /> Signed - i. Da <br /> Authorized Representative <br /> Date <br /> Name of Driller <br /> WATER WELL 4 3 4 017 717' <br /> 7/70 30M <br /> 7178 9UM <br /> CONTRACTOR COPY HE-01206.02(Rev.10/85) 2/82 101A <br />