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STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> 1. A o WATER WELL HECOHD �N/NNESOTA UNIQUE WELL NO. ! <br /> County Name t o�o iJ� <br /> � ..��r a... Minnesola Slalules/56A.01�.08 /%Wafer Samp/e <br /> 1"�;.S 4IE..:1XF <br /> Township Name� ownship Number Range Number Section No. Fraction 4.WELL DEP7'H(completcdl Date of Completion <br /> .. . l.1 r ° _. ° �".- i'" y �i `t` � , <br /> w �i ;�-� 1-� ' n. r- <br /> Numerical Street Address and City of Well Location or Distance from Road Intersection. 5. DRILUNG METHOD <br /> .�. ❑Cable"1'ool ❑Reverse ❑Driven <br /> ❑Dug <br /> ��,v - �-� r��._ . <br /> ' .(.k�..�C 11.�. h' � v. 't cJ:. ��.: -'CL '���.._� t'Li1_i t. � � :7.,� <br /> ow exacl location of well in section grid with"X." Sketch map o(well location. ❑HollowRod ❑Air ❑Bortd ❑ <br /> N <br /> � � 1 _i_ Addi[ion Name ; � �� -�� � �� C7�Ro[ary ❑Jetted ❑Power�Auger <br /> --r- -t- - � � � :-. <br /> � ' .... . �� 6. DRILLING FLUID �� <br /> � <br /> --+- -'- �- �- Block Number � ... . . <br /> W � ; i E 7. USE <br /> i <br /> _1_ _1_ _'_ __ T . � �Domestic ❑Monitoring ❑Heal Pump <br /> 1 ' � � . Lot Number <br /> ' f,m�. �..,..,. ❑Irrigation �O Public O Industry <br /> � � � L]Test Well �O Municipal O Commercial <br /> --�- �� - -r- - ❑AirConditioning ❑ <br /> i <br /> I mile—� 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address ❑g�a�k ❑Threaded HEIGHT:Above/Below <br /> � - indicated above. Surtace tt. <br /> �:L�:� +i ". . _._... ❑Galv. ❑Welded .. . <br /> Drive Shce? Yes�°.� No— il 1f r-���� <br /> ,b+ Plastic ❑ <br /> r <br /> '1 in.to �`' ft. Weight�IbsJtt. �n. to•�t. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to (t. Weight Ibs/tt. �n. to_�t. <br /> FORMATION <br /> ' y t"' <br /> in.to (L Weight IbsJft. �n. to—It. <br /> -, ,iiii� 9. SCREEN Oropen hole <br /> Make +'L���11i:��.1'11 trom (t.to. (t. <br /> il:i :3, T :,L_-ir.�e� .:d-.. �;r� <br /> .1...`;'"1 YPe '.'`1 D1am.- _. <br /> 1;: - _ <br /> SbVGauze Length •- <br /> - � FITTINGS: <br /> Set hetween •����%- ft.and 1.'": ft. <br /> ]0. STATIC WATER LEVEL <br /> fL O�below ❑above Date Measured `'��-"�-�� <br /> land surtace <br /> 11. PUMPING LEVEL(below land surface) � <br /> tt.atter ��- hrs.pumping �i+ g.p.m, <br /> '';�� (t.after hrs.pumping g.p.m. <br /> S <br /> 12.HEAD WELL COMPLETION � <br /> :L]Pitlessadapter manutacturer �_'��'1'��"'EY i"j�'����-„'y;� Model <br /> IO Basement of(set :�At least 12"above ground <br /> ❑Plastic casing protection <br /> 13. WELLGROUTED? J�Yes O No <br /> 1� >;,O Neat Cement ❑Bentonite L7 <br /> Grout material (rom -�i-' to (t.cu.yds. <br /> p�G <br /> ' r � 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> (ee[ direc[ion �yce <br /> Well disin(ected upon completion? i�A Yes ❑No <br /> 15. PUMP <br /> Date ins[alled -�=����-�.` � ❑Not installed <br /> Manufacturer's name��?�'�_ <br /> Model number ' HP_��Volts - <br /> Length of drop pipe ft. Capacity �,� g.p.m. <br /> Material of drop pipe.y�� l a=o��c.�� <br /> Type:s�]Submersible ❑L.S.Turbine C]Reciprocating <br /> OJet ❑Centritugal L7 <br /> 16. ABtWDONED WELLS <br /> Unused well on property? G�yes ❑No <br /> Use a second sheel,i/needed Sealed .'� Permanent ❑ Temporary ❑ Not sealed <br /> 17.REMARKS,ELEVATION.SOURCE OF DATA,etc. <br /> • 18.WATER WELL CONTRACTOR CERTIFICATtON <br /> This well was drilled under my jurisdiction and this report is true to Ihe 6es[of my <br /> knowledge and beliet. <br /> e A _� :`tl/��'«i` k�;'.;�.�,. �iC.�.�yi��.i�'„�.'r ..i.%. � �e� <br /> �i <br /> Lirensee Business Name License No. <br /> . . : _ -- , , , -. . - <br /> Address -�-� ��:� S ��iz:?:�. :; i� irt"1`�%'.«.r .-:�i��i •`' `".` <br /> . � .:� r'� �' ,r' . <br /> ,. / - �.._.:�,._�.;. <br /> SiS�ed � � -'�r��f �/ J ``�.;,r'- Date�„ . . _ <br /> ��j -���.... <br /> Authortzed Represenmttue <br /> . . , i' ;::�;.�.`i���.... DatP ... ...t-,M�-.'. <br /> Name ojDrilfer <br /> G050H7 5„°�" <br /> IOCAI COPY 77630"' <br /> �ne 3onn <br /> HE-01205-03(Rev.9/88) yi82�p�,� <br />