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i <br />Ex <br />STATE OF MI1fESnTA <br />DEPARTMEM W HEALTH <br />Cot�fjr%sr � lrarttcr� �� �er�lon 11 r 1lysn <br />stenos end M rection from Road intersections or Street Address and City <br />M <br />Q. <br />an of well in seetim frill with -X. <br />M <br />&Zia <br />E <br />T <br />l <br />J <br />------4 <br />rGMT10 6% <br />:UX�tC►I1+C <br />5. PBMAP><11. EUITATIOs . <br />LOCM COPY <br />MATER wLL. RECORD <br />71mweata 'tat.tee 4,3".01 ,0I <br />nip Number Pemae Sumber 13. <br />7 <br />map or well 1 <br />ftlowsom UNIQUE kwu W. <br />for later :-wV1e 1110 0 3 <br />2 Chem Avbrm <br />r <br />wa• _ <br />• Caapls r Orte of G'aeplitiae <br />- 277' _ ft. j X1.2--€�4--€�4 <br />j <br />ble tool Pevarse l(� ori ven IOQ Daftlle rod 5] Alr "Lor!coredLWr 60 Jetted �(_] t�u.er Auger <br />4h - <br />245 124: <br />Iliftmatic L P,*IiC Duppiy 7z:j Imdustry <br />'[]Irrigation SE]Atr Conditioning it]Ccsereial <br />1C] Test Well 60 <br />:IiAR. <br />lhroaded welded Q Eutrlfaes ft. <br />Black [ Galr. <br />in. to__269 rt. depth woom 10-86 ris.m. <br />In. to` _ft. deptb <br />is. to __ft. depth Drive Shoe? Too so <br />Or open bole ! <br />Mate ictmom fro. ft.2! to A it. <br />7y," stainless steel Dia. L— <br />SIt,Gaus. 10 LOMU 1 • <br />Set "two" 2,69 ft. end 277 rt. <br />ft. Ane It* <br />ft. and it. <br />. (abolat [] above Dass <br />32 ft. after—4 Ire. puiplas 20 t.p.m. <br />h , after hrs. pumping s.p•a• <br />I1:Y%tlesm adapter %L] Basement offset IQ At lost le sties <br />s.. .... as....... <br />[yes [:) so Cu. T4A, w <br />1(] Beat count 213 Bentonite q lb� iU <br />IMpth! from ft. to ft. <br />rrom ft. to ft. <br />13. nearest source of possible conteaimatlon <br />feet direction �____— type <br />Well disinfected upon Completion? Teo 11 so [] <br />Data Iwtmll" 3w�• • <br />[]Not insUaled <br />•7i Manufacturer's Isms <br />itodel Number BP .•�%dw <br />Longed of Mop pipe ft. eap"Ity ���.p.a. <br />Material of drop pipe <br />typo; 1915dwersible 30 L.B. Turbine 50 Reciprocating <br />2c] Jet 6[] Cemtri rv4p1 60 <br />This well was drilled under mV jurisdiction and this report is true to <br />t1w best of Mr kmowleAm and belief. <br />Di 6=010 hills MILLOde Me- --- _ 172. <br />--�yae�no..ZioAmr seta - <br />Address 15306 RV mirm, 55m <br />_- <br />12-13414 <br />Jowl Dote <br />Authcrtted Aepretentative <br />F• Z3 • 1 m%:fix d1 <br />n■r of Driller <br />, <br />- <br />-4- <br />i <br />&Zia <br />E <br />T <br />l <br />J <br />------4 <br />rGMT10 6% <br />:UX�tC►I1+C <br />5. PBMAP><11. EUITATIOs . <br />LOCM COPY <br />MATER wLL. RECORD <br />71mweata 'tat.tee 4,3".01 ,0I <br />nip Number Pemae Sumber 13. <br />7 <br />map or well 1 <br />ftlowsom UNIQUE kwu W. <br />for later :-wV1e 1110 0 3 <br />2 Chem Avbrm <br />r <br />wa• _ <br />• Caapls r Orte of G'aeplitiae <br />- 277' _ ft. j X1.2--€�4--€�4 <br />j <br />ble tool Pevarse l(� ori ven IOQ Daftlle rod 5] Alr "Lor!coredLWr 60 Jetted �(_] t�u.er Auger <br />4h - <br />245 124: <br />Iliftmatic L P,*IiC Duppiy 7z:j Imdustry <br />'[]Irrigation SE]Atr Conditioning it]Ccsereial <br />1C] Test Well 60 <br />:IiAR. <br />lhroaded welded Q Eutrlfaes ft. <br />Black [ Galr. <br />in. to__269 rt. depth woom 10-86 ris.m. <br />In. to` _ft. deptb <br />is. to __ft. depth Drive Shoe? Too so <br />Or open bole ! <br />Mate ictmom fro. ft.2! to A it. <br />7y," stainless steel Dia. L— <br />SIt,Gaus. 10 LOMU 1 • <br />Set "two" 2,69 ft. end 277 rt. <br />ft. Ane It* <br />ft. and it. <br />. (abolat [] above Dass <br />32 ft. after—4 Ire. puiplas 20 t.p.m. <br />h , after hrs. pumping s.p•a• <br />I1:Y%tlesm adapter %L] Basement offset IQ At lost le sties <br />s.. .... as....... <br />[yes [:) so Cu. T4A, w <br />1(] Beat count 213 Bentonite q lb� iU <br />IMpth! from ft. to ft. <br />rrom ft. to ft. <br />13. nearest source of possible conteaimatlon <br />feet direction �____— type <br />Well disinfected upon Completion? Teo 11 so [] <br />Data Iwtmll" 3w�• • <br />[]Not insUaled <br />•7i Manufacturer's Isms <br />itodel Number BP .•�%dw <br />Longed of Mop pipe ft. eap"Ity ���.p.a. <br />Material of drop pipe <br />typo; 1915dwersible 30 L.B. Turbine 50 Reciprocating <br />2c] Jet 6[] Cemtri rv4p1 60 <br />This well was drilled under mV jurisdiction and this report is true to <br />t1w best of Mr kmowleAm and belief. <br />Di 6=010 hills MILLOde Me- --- _ 172. <br />--�yae�no..ZioAmr seta - <br />Address 15306 RV mirm, 55m <br />_- <br />12-13414 <br />Jowl Dote <br />Authcrtted Aepretentative <br />F• Z3 • 1 m%:fix d1 <br />n■r of Driller <br />