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STATE OF MERIESOTA DEPARTIEIIT OF HEALTH <br />UP 9W <br />Casaay <br />WATER WELL RECORD MINNESOTA UNIQUE WELL NO. <br />fie; u K: r ;1n <br />Miaa..b sUAda ,16A. o, �.75 IN wet" s. <br />469550 <br />Tassaltup Now. <br />her <br />Number <br />Srctson No <br />Frw m <br />a. WELL DEPTH icaapirtedi <br />an <br />11:1 v <br />t' <br />SAi -4 Wl 14 SU-AT7,_ <br />al Serrate Addness and City <br />or theu Loesimn or Distance from Roil Irsterseection <br />S DRILLING METHOD <br />1t). :itr:'-'.L, <br />Uruv_,, Mina. ��! — • <br />OCOWTool ORnww <br />Ohollow, kod OAir <br />ODrivers ODq <br />0Owed O <br />sawenactlocationIall <br />well in Instant" wmh"x." map of well leconsin. <br />I e <br />I I <br />Addition Name <br />dliRa+ry OJetted <br />O Pbwv Auger <br />W r t E <br />1 t ' I umber r <br />Y• v <br />y address <br />2. PROPERTY OWNER'S NAME Mailing Address if different than propert <br />indicated above. <br />k3ute 3 4 BOX 3S <br />D0,111 Yeri'.4;111 lC>lL:t !ll('�? .NI Iucintl, f$1. r7LINi <br />J. FORMATION r.s.s. <br />LOG COLOR .�.._0 <br />�l <br />'i ftJQ bAm O aA»e Date Measured I�� fia+ir-- <br />land surface <br />I1. PUMPING IEVFL ibrk w land surfarrl <br />y fl. after li hn pumping Li� i p.w. <br />11. after hrs pumping spa. <br />12. HEAD WELL COMPLETION <br />&PHtlessadspier manufacturer t Madr <br />❑ basement offset Ai At kast 12' abre ground <br />❑ Pla" w casing protection <br />17. WELL GROUTED? CkYes O No <br />O Neat Cement O 6entowte <br />Grout materwl . from to Itat. ptY_ <br />la. NEAREST SOURCES OF POSSIPLE CONTAMINATION <br />feet director <br />Well disinketed upon completion? )oYn ONO <br />ttiye <br />15 PUMP <br />[Ate installed ., —� —`a <br />O Na , 0 <br />Manufanureis name scr <br />- <br />, ;^ <br />Model number HP <br />Vale. `e• <br />Length of drop ppr 14 1 It. Lapscrty <br />Material of drop lips, l tt Gai , _ <br />S Rsa. <br />TypeV SuMue able O LS. Turbine O Reciprmsfuss <br />Olet ❑ Centrifugal O <br />16. ABANDONED WELT S <br />Unused well on property? O Yes gkNo <br />Usr a srraa/ <br />sbnrt. r w" <br />sealed ❑ Perwwten1 O Tewplany O NO gram <br />17. REMARKS. ELEVATION. SOURCE OF DATA. etc. <br />is. WATER WELL CONTRACTOR CERTWWATION <br />This well was drilled under my runub"wn will this ripe is true <br />to the bend of gay <br />k owleds and edict <br />Lrraaw wsivm Mar <br />Lirsar Na <br />Addrasit -e.h Ht eft.L,�,/�.C�. �`I/' ;./i�ii3 <br />.�` i4:, <br />- <br />Authoesid ftpo nor <br />}'_ Y_ Mf±4jr1. Ar <br />Nsmr aJ arm" <br />LOCAL COPY <br />gtya1101 <br />RAl <br />4695501 <br />�EiIRMn �Ml <br />7„gat <br />g,Y <br />