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WELL LOCATION <br />MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br />WELL RECORD 01 <br />County <br />ou ny Name <br />lir ru K>nin <br />56 1 87 <br />MirUtesofa Sratufes ChVfer 1031 <br />Township Name <br />Township No. <br />Renpa No. <br />Section No. <br />Fttacdolt <br />WELL DEPTH (completed)Date <br />Work Completed <br />Orc'no <br />1 1 ; <br />23 <br />04 <br />14d:' n <br />- , - <br />Numerical SU" Address and City of Wall Location <br />or Fire Number <br />DRILLING METHOD <br />C /t'�. C401Mt-.1yj 1jcil2 bri-,,e Lmig Iake_,T <br />1. <br />❑ Cable Tod :1 DnVen C.: Dig <br />❑ Auger Il Rotary L] Jelled <br />:7 - - --- - — -- - --- <br />Show exact location of well in sedan pend with 'X', Skelcn map d well location <br />55356 Showing kala. <br />property <br />N roads and buldngs <br />DRILLING FLUID <br />' ' X <br />USE <br />la Domestic n Monitoring He" im <br />I l <br />W l E <br />rI Implion ❑ Puck ) IndutrytCo <br />I 1 <br />RemoryeCorrmnercial <br />L] Test Well D Dewatarnp ..1 RemedW <br />n <br />e' <br />CASING Dnve $fnoa7 c rn I-: No <br />HOLE DIAM. <br />• / <br />I <br />11 <br />t - -i -d <br />L, Si" :J Threaded 11 Welded <br />1 miss, <br />Fj Plastic—_ -- <br />CASINO DIAMETER WEIGHT <br />` — n. ro 13N <br />PFIOPERTY OWNER'S NAME rc � -t i r lackm (lxT til <br />_ . y <br />--- in. to -- n' - - - - ---- - -- - _.. lbs rtt <br />– -__-. -- in. to h. "J" <br />-- -- <br />_ on. to — h. <br />M&WV address 0 dot WI than property address indicated above. <br />4 1 i,A , Bert'.::rdre Line <br />SCREEN OPEN HOLE <br />I'Ijq!IC;Ut,'1 Flt 1.:. ` � 1 r- h <br />_ <br />1i1 1 - on <br />Make from <br />a <br />Type st r:1i11C�::: :i1 LE1 Dam. _-_ 4 <br />« 4 -- <br />Set between _ ' y t. and �'� it. FITTINGS: <br />GEOLOGICAL MATERIALS <br />COLOR <br />HARDNESS OF <br />MATERIAL <br />FROM <br />TO <br />STATIC WATER LEVEL <br />L -- R. Al below 'I above lard surface Dile meesured <br />,-IV & a il1c l <br />;. <br />r <br />1 ' <br />PUMPING LEVEL (below land surface) <br />R. after -- -- Ms. puntpeq p.p.m. <br />&Intl <br />�. <br />1:.I <br />1:: <br />WELL HEAD COMPLETION <br />Ciwele.sadaptormenufactla« i*:earit_er Moa.I -- <br />❑ camp Prowlon 2 in. above grade - <br />GROUTING INFORMATION <br />We' prolMd9 Yee ❑ No <br />Grout Mahal ❑ Neal cement 4111anics <br />u <br />from-'- .w. to it_. R J ❑ )`s.* beg <br />from _ to n. ❑ yds. ❑ baps <br />from to n. ❑ yds. ❑ blip. <br />NEAREST KNOWN SOURCE OF CONTAMINATION <br />-N- -._ 7 dkecUon ,SCS NPe <br />Waa awit.aw upon complertm? R res ❑ No <br />PUMP <br />❑ Not e+ataaed Dan installed 10-3-" _ <br />Manufacturersname <br />Model number HIP1 _ S_ 5 - -- Vofb 730 <br />Langth d drop pipe - tiv�S -- - R CapecM - 7�7-- 9.p.m. <br />Pressure Tait Capacity <br />Type: n Submersale ❑ L�. x�e��tnp ' I Jet --- - ---- — <br />ABANDONED WELLS <br />Does property have any not m use and not sealed well(s)' :; res 9. No <br />- <br />WELL CONTRACTOR CERTIFICATION <br />Tris well was o lied _ndar my supervision and in accordance with Minnesota Rules. Chapter 4725. <br />The mformab on contained in On report q true to ft beet of my knowledpe. <br />Use a second sneer ,f needed <br />UGN :, A DLU, hl" MUTAIG CU., IANC.. 71 i - <br />REMARKS. ELEVATION, SOURCE OF DATA. etc. <br />LkenewBluaeraarNanre 1.4 or PAW No. <br />Owe <br />F.P. McMahui 9-119-9 <br />Name or Drme, pipe — <br />HE -0b 2OS•04(Rev. SM) <br />LOCAL COPY <br />.387 <br />