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WELL L. CATION MINNESOTA DEPARTMENT OF HEALTH M!NNESOTA UNIOUE WELL Ali <br />County Name Henrwipi.n WELL RECORD 5 q <br />Minnesota Statutes Chapter 1031 <br />v <br />Township Name Township No Range No Season No Fraction WELL DEPTH (completed) Dale Worts Cixripleted <br />h <br />Numerical Street Address and City or Well Location or Fire Number DRILLING METHOD <br />1 h `,1 CYO]; street O C a x1, mn . Cable Tod i Driven i ; Dug — <br />Auger jJ Rotary 1 <br />Slow eaaa location of well in section grid with 'X' Sketch map of well locat <br />nuoulmmon <br />I t hilts <br />Showing property li -. _ - - __ - ----LAM <br />- <br />roads and buildlin s. DRILLING FLUID <br />Ben tnj <br />.USE !-I HeatnpR7ooyp <br />I <br />�. Domestic t 1 M Public: <br />g C7 ktdutrycorrime crM <br />/Irrigation] PuDkc ❑ Rentsdiel <br />tt { Test Well i : pewNMirq <br />AN <br />CASING Drive Threaded <br />[ Yes Ll No L,JI� HOLE <br />k 0 Steel I. Tbrsadad ❑ <br />-' <br />w Plastic it \11j�-J <br />1,��• CASING DIAMETER WEIOHT <br />PROPERTY OWNER'S NAME <br />i a ri <br />J i-r, .. kmf e!l fiLx es <br />_— on to — h <br />1'' • 66 <br />bJR <br />� '% <br />h. b A— <br />_— a .to _ h. <br />_--- -- in, to ._ h. <br />bJll <br />_ Itlrull. <br />= 1n. for IL <br />in. to —1 <br />Maang address A d Wenl than property address indicated above <br />f' 1 r 1 !P rkwny <br />SCREEN —jh <br />� N HOLE <br />�linrx�`. cri'c�:, I�6T._ :� <br />Type Uteel <br />Dim <br />SbVGauze—� r <br />LWVMt <br />' ` <br />Sat between ► 1 t _h. ands7-_h. F1nwas: <br />GEOLOGICAL MATERIALS <br />COLOR <br />HARDNESS OF <br />MATERIAL <br />FROM <br />TO <br />STATIC WATER LEVEI <br />S h. Ulbabw ❑ sbpteare•wtaoa Dan <br />C:Liy <br />t, <br />PUM L (below lard surface) A <br />2rt <br />1(- <br />h. stir <br />_ In. ptaltpatq nn�w. <br />WELL HEAD COMPLEriN .: < <br />. <br />�_.' onf'.Fji <br />CRP, a plsr msr.Aec�r <br />❑ Calling ProNctgn -- -- <br />Modal <br />49 12 in. aboir. wmb <br />Wee grotAw ❑ Yee Q No <br />Grout Malarial ❑ Nets cow p 9erttarlits <br />from b IL ❑ yds. ❑ bop <br />from b It. -- ❑ yea. ❑ bare <br />from_ to K ❑ yft ❑ up <br />NEAREST KNOWN SOURCE OF CONTAMINATION <br />I" dYMOMon qp <br />Well dawillecilled upon complatlmT ❑ VM ❑ No <br />PUMP <br />❑ Na irtst.aw Dec. etM.rw <br />6-1c:—y: <br />Manufacturer's name X-• <br />Model number --- ►O ._e, _ Vo% f l <br />Length of drop tape __ r�i'iC1`141 <br />PreawreTnkCa{Nuty Pregt+Idr(+ TPnk <br />Type: Cl Su.mwsible ❑ L.S. Turbine ❑ Rspgoea" ❑ JM ❑ <br />ABANDONED WELLS <br />Does p•^.'- have any rid in use and not aeeled w1(s)9 ❑ Yw Q No <br />WEU 'OR CERTIFICATION <br />This w. ..under my supemwn and in aooadMtce war sUtrtaso4 Ruin. CMpNr 4725. <br />The im. --.. "lained in ees report is true to I* bets of my', dp. <br />Use s second sheer. A needed 0RJ1.UNU CV <br />REMARKS. ELEVATION, SOURCE OF DATA, etc. L.cerrsea Busrwsa sy"'s lle. or Oft No. <br />1-1ls-9? <br />-- Nit. a orwlw - --Dam - <br />LOCAL COPY 15204591 ME•01205-M(Retn. 5" <br />