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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1.LOCATION OF_WELL I„srl, <br /> WATER WELL RECORD MINNESOTA UNIQUE WELL NO. C o <br /> County Name t for Water Sample J <br /> �, Hen Minnesota Statutes 156A.01-.08 <br /> 4. T--ship Namei Township Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion <br /> oCu� 117 S 23 W 07 SE 'Am'/MW 83 I ft. 8-13-91 <br /> Numerical Street Address and City of Well Location or Distance from Road Intersection. 5.DRILLING METHOD <br /> 1003 Wi].b rst Trail, r * 66364 ❑Cable I'ooI ❑Reverse ❑Driven 13 Dug <br /> L <br /> Show exact location of well in section grid with"X.” ,...to . • Sketch map of well location. CI Hollow Rod 0 Air 0 Bored O <br /> N X" <br /> t 1 - Addition Name j-^ �1 <br /> tprcotary 0 Jetted 0 Power Auger <br /> __r-- _ _i__1_ 6.DRILLING FLUID <br /> I <br /> I <br /> i 1 I Block Number 'Y; 7. USE <br /> XDomestic 0 Monitoring ❑Heat Pump <br /> , i I Lot Number 0 Irrigation 0Public 0 Industry <br /> • F•mi. ❑Test Well 0 Municipal 0 Commercial <br /> --1- --i- i--r- 1 I I LI Air Conditioning 0 <br /> 1—I mile 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME MailingAddress if different thanpropertyaddressHEIGHT:Above/Below <br /> 0Black 0 Threaded <br /> indicated above. Surface ft. <br /> Harriet V t 0 Galv. 0 Welded <br /> J. �tDrive Shoe? YesX No__ 6 <br /> IXPlastic ❑ 1/4N <br /> 4 in.to 79 ft. Weight 1.90 lbs./ft. to 8a <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight lbs./ft. Win. tort. <br /> FORMATION <br /> in.to _ ft. Weight lbs./ft. Win. to_ft. <br /> Clay Q 70 9.SCREEN Or open hole <br /> �'otnson , from _ ft.to. ft. <br /> �+.,�� Make Stainless�.,,1 �y��� <br /> Sand 70 83 Type Stri inle s Steel Dram. a» <br /> Slot/Gauze 10 Length <br /> _Al__ FITgNGS: <br /> Set betweenft.and 3ft. <br /> 10.STATIC WATER LEVELq45 p _ <br /> ft.D�elow 0 above Date Measured E)"'13-91 <br /> land surface <br /> 11.PUMPING LEVEL(below land surface) <br /> ft.after hrs.pumping g.p.m. <br /> ft.after hrs.pumping g.p.m. <br /> 12.HEAD WELL COMPLETION �,2 <br /> APitless adapter manufacturer y *j..t a litter Model <br /> 0 Basement,offset 1b At least 12"above ground <br /> 0 Plastic casing protection <br /> 13.WELL GROUTED? Wes 0 No <br /> XI Neat Cement 0 Bentonite 0 <br /> Grout material from 30 to___O____ft.cu.yds. _ <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction type <br /> Well disinfected upon completion? CMes 0 No <br /> 15. PUMP <br /> Date installed 8"-30.91 0 Not installed <br /> Manufacturer's name <br /> Model number HP 3/4 Volts 230 <br /> Length of drop pipe 60 ft. Capacity 12 g.p.m. <br /> Material of drop pipe 1" Galli. <br /> Type:XI Submersible 0 L.S.Turbine 0 Reciprocating <br /> ❑Jet 0 Centrifugal 0 <br /> 16. ABANDONED WELLS �,/ <br /> Unused well on property? 0 Yes )(lo <br /> Use a second sheet,if needed Sealed 0 Permanent / 0 Temporary 0 Not sealed <br /> 17.REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> • 18.WATER WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. <br /> . DON &IMOLA MEL DRILLING CO., INC. 27172 <br /> Licenseel�eBusinessBu� Name License No. C <br /> Address <br /> 115306 Highway #7, Mtka, W. 55345 <br /> Signeh - ' -'! .._ ,1!;i :L� /' Dare 8-13-91 <br /> Authorized Representative <br /> F. F. McMahon Date 8-13 91 <br /> Name of Driller <br /> LOCAL COPY 475750 5/7430M <br /> 7/76 aoM <br /> 7/ 8 30M <br /> HE-01205-03(Rev.9/88) <br /> 2/82 1OMM <br />