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Hejinepin <br />STATE Of MINNESOTA DEFATTMENT OF HEALTH <br />WATEH WELL RECORD MisshSOTA vstQVt weu so. <br />r Sh/Mla I56A 0I 08 /Of WtUr Samtit 467082 <br />fl£S5%^, <br />TowMhip Number Ilange Number Section No Fraction 4 WELL DEPTH loompleted)bateof CamplelionNwVi 14 W <br />W ------------------!L . 1 QQ <br />4750 Creekvood Terrace <br />Shem cuct lontian cl wcirtn Mciion grid with "X "Stoch map ol writ knlion <br />••r-4--i--f- <br />T I <br />■ ^ - <br />-i--i-■f <br />■t --i--i-1"r* <br />□ Hollow Rod □ Air □ BorM n <br />□ Jetted □ Power Auger <br />6 DRILUNG FLUID <br />7 <br />CieomeaiK □ Monitonng □ Heat Pump <br />□ Imgainn □ Public □ Industry <br />□ Test Well □ Municipal □ Commercial <br />t PROFERTY OWNER'S NAME <br />Roben Corporation <br />FORMATION LOG <br />yellow clay <br />clay <br />gravel & clay <br />sand <br />Mailing Aiidress if diffrieni than propcny address <br />indicated above. <br />2765 Kelly Ave. <br />COLOR rrmFirri^T*: <br />brown <br />gray <br />gray <br />brown <br />FOmAnON <br />soft <br />soft <br />soft <br />soft <br />FROM <br />148 <br />□ CaUeTool □ Reverse □ Driveti □ Di« <br />8 CASING <br />□ BUch <br />□ Citv. <br />D Threwded <br />□ WcUed <br />*"‘•"4 °151 <br />--------------------in. to_________ <br />. in. to. <br />. in. to. <br />HEIGHT: Abovc/Below <br />Surface--------------------------It. <br />Dnve Shoe? Ye-___No____ <br />We«ht_____________Ifcayl <br />We«ht <br />We«ht <br />. IboVlt. <br />. IbiVfl. <br />HOUDIAM. <br />Jn. to_____ft. <br />Ja to_____It. <br />9. SCREEN <br />Johnson Or open hole <br />tram________.ft. l& <br />stainless steel <br />12 slot Leiigth.5 ft. <br />Set between .. ft. and. <br />hrrtNcs; <br />3 ft. extension <br />10. STATIC WATER LEVEL—um (t.O below □ above <br />land surface <br />Date Measured 10/25 <br />11. PUMPING LEVEL (below land surface) <br />-----------------------It. after ______ hra. pumping . <br />-----------------------ft. after______________hne pumping . <br />■ P-m. <br />gpjn. <br />12. HEAD WEa COMPLETION <br />Qfitless adapter manufacturer___________________ <br />□ Basement offset □ At least 12" above ground <br />□ Plastic casing protection_________ <br />JX WELLCROir-' <br />□ Neal Cement <br />Grout material _ <br />□ No <br />. ft cu. yda- <br />eg <br />14 NEAREST SOURCES OF POSSIBLE CONTAMINATION <br />---------------feel__________direction ________________ <br />Well dmnfrcird upon rompielion’ C|(ea □ No <br />Vtr outottiAtH. tf rnidml <br />'■0 <br />|UMP <br />installed _ <br />iifacturer's i Aeraotor <br />.□NMinatalled <br />Model I <br />Steel <br />CapacityLength of drop pipe — <br />MalensI of drop pipe <br />Type: % Submersible □ LS. Turbine □ Redprocaling <br />□ Jet □ Centrifugal □___________________________ <br />hiIJl. <br />12 <br />.Volta 230 <br />16. ABANIXINED WELLS <br />Unused well on property? □ Yes dDio <br />Seided □ Permanent □ Temporary □ Not sealed <br />17. REMARKS. ELEVATION. SOURCE OF DATA. etc. <br />18. WATEP WELL CONTRACTOR CERTIFICATION <br />This well was drilled under my junsdiciion and ihu report n true to the best of my <br />knowledge and talirf. <br />Leuthner Well Inc. 10125 <br />Addres <br />Litrmtt Buitmas Somt Limit No <br />.Box 159, Victorias Mn 55386 <br />P .., VcH.. <br />Ken S^hjrft^ <br />LOCAL. COPY 46/U82 <br />Namoq/DttUtr <br />HE4UB549(llev. WEB) <br />nsr./ '/■ // /H <br />10/27/90 <br />■ Date______________ <br />S/74 30M <br />7/76 aOM <br />7/76 S6M <br />VM 18M