Laserfiche WebLink
� STATE OF MINNESOTA DEPARTMENT OF HEALTH <br />� A WATER WELL RECORD M/NNESOTA UNlQUE WELL NO. �����^ i <br /> Cwnry N�n , � <br /> Minnesoto Sfotutes 156A.Od,08 I�Woter Snmpk � � <br /> Toanship Name� Tow�n+s�h*i�p,N�um Rayn�ge Number Secti.oten�No. Fraction 4.WELL DEP1'H(mmpleted) s Date of Completion ' <br /> .ii,�'<.1 � +G�7'it� W �&+� �rY' �� ��i� �/+ .1.� ft. ���� I� <br /> Dietance and�D�irectiun fran Road Intersection m Street Address and City of Well I.acation � G METHOD � <br /> •�-� ,�.' �W ��^7�o6ii �� � 0 4O Reverse 7O Qriven 100 Du8 � <br />� ow exact locatianN well in sectinn grid with"X:' - Sketch map of well 1 0 11i�F ��red 1t� i <br />� � � � i Addition ame � otary v 9O Power�auger i <br /> --r� -1- -1 -1- 6• G Ulp I <br />� � � � <br />{ I � � Blak Num6er � i <br />' W•-�- '�- �- �- E ZU <br /> I � lp ' 'oring 8O Heat Pump <br /> _.L_ 1_ <br />� � � � � �k mr. 1'°t Number 2O Irtigation 9O Industry <br />'' � � 3p Il Mu iapal I�Commercial <br />�' --�- i- � —r- I 7OAi Conditioning 11� <br /> � � � 1 i <br /> r �1��_� 8.CASING HOLE DIAM. <br /> 2.PROPER7Y OWNER'S NAM1E HEIGHT:AbovelBelow <br /> 1�Blazk 4f]Threaded i <br /> 4;�'■ � �`�� Surface �at. I <br /> „�P„� � �Galv. 5p Welded <br /> �� L� Drive Shce? Yes—No— <br /> �.�� �$,��' a� ���'�� 30Ptasyc ��c�� �.�� cf_ .�F� I <br /> � in.w ft. Weight Ibs✓ft. �n. to—tt. <br />� s I <br /> 3. FORMATION LOG COLOR HA����F FROM TO in.to ft. Weight lbs./ft. �n. [� h <br /> k FORMATION <br /> p in.to ft. Weight IbsJft. �n tu—ft. � <br />� � 1 ��� � � 9.SC Or oP�hole I <br /> f fm+�+ ft.to. ft. I <br /> 'x� � M� � <br />� ai. <br /> .. _ T� II�s.��— I <br />� M SIoVGauu �S�h <br />� ��� • � � Set between^ ft.and it. FI'fTINGS: i <br /> �� � � <br />�; 10.STA�t�WA7'ER LE�L ', <br /> I� �`� �� �� � � h.O below O abtwe Date Measured <br />�: land surface � <br />�I �r,.,� ✓ 11.PIIMPING LEVEL(below land surface) � <br /> p �.'�+iii# �l '��'.� � „ ��- �� �� ft.after hra.Pumpi� �� &P.m. I <br /> �,rj � ft.ahei hre.pumping g.p.m. � i <br />� ��; � �'� _ �� ����: :� <br /> 12�IEAD WELL COMPLETION � <br /> 1T�Pitless adapter.manufacturer male� I <br />�, � ,�, �' �� � �,�}� 2O Bea�nent offset 3O At least 12"above ground I <br /> G 40 I�lastic casi�protection <br />� 13.WELL GROUTED? <br /> �Yes ❑No ' I <br /> 10 Neat Cement 2C7 Bentonite 3O i <br /> Grout material from to R cu.yds i <br /> T— I <br /> i ` <br /> 14.NEARFST SOUItCES OF POSSIBLE CONTAMINATION <br /> feet directi±o�n ,,... <br />� wen a�9�r����Piec�r "L%Yes ❑No <br />� 15.PiJMP � <br /> i <br /> Date installed �, ❑Not irretalled � <br />� Manufacturer's name � <br />� Madel m�m6er HP�Vol�s i <br /> IeoSth of droP P1Pe � k. , caPecity &P.m. j <br />� Materiae�l of dmP P�Pe � <br />� I <br /> Type:lII'Submeraible 3O L.S.Turbihe 50 Reciprawting <br /> 2C7 Jet 4O Centrifugal � <br /> i• t6.EXISTING WELLS �p j <br />� Unused well an prapertY? G'Yea ❑No I <br /> Use o setond sheel,iJ needed � <br />� l7.REMARKS,F.I.EVATION,SOURCE OF DATA,eu. Abando� �Permanent O Temporary O Not sealed <br /> • I8.�PATER WELL CONTRACTORS CERTff[CATION <br />� This well was drilled u�er mq jurisdiction and this report is true to the 6est of my <br /> knowledge and 6eliet. I <br />�. ����� '� �. ��� <br />� �e a��No,� u��ro. <br /> F ,�` � " . �� _ _ �` ` .�� ���� i <br /> - � a ;� ., $ ; <br />� �„�.t;;?,--:.s.�_<�` <br /> � <br />� S�� �a,c„c �'�,�-�,� pa�p ���"�� i <br /> Authorized Representati�e <br />� - e�� � Name of Ikiller DarP �'��•'�� <br />' LOCAL C�OPY 4 4�7 7 2 7;�� � <br /> �,�� <br /> F�-0120502(Rev.lOB5) 2/82 tOM ' <br />