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tiTAT4:Oh�MINNI�:S()TA UF'.1'AN7'M'cNTOI�HF:ALTH <br /> I. Lnl'ATI<)N UI�WI LL FIlNNFSOTA UN/QUF WEl.L NO. �^� r !"� �` � y'R, <br /> ������rN,��. WATER WELL RECORO <br /> .�ea�w in ,�.Wa,�.Sam,�� .�.�°:: _� k�� 4 <br /> Minnefr)!a Sfa N feJ I SM1 A.fl l�.(�N <br /> Tnwnsnlp Name Tnwnship Numher Nan{e NumAer tiecll�in N�. I�r�cli�in J. NROYlRTY R'S NAMF; <br /> N ' g 'G v. v. - <br /> 31"j °s' � w �# �,iT'!'y ::a. :�.1�i 2 � <br /> I)�atance and Ilkecl�iin(rum N�uJ inlrrsecli��nc�ir Slrcel A�Jress anJ C'i�y of Well Lo<�lion Ad rtsf ��y,.y}�,,,.�.3� �� <br /> w•sa,� a�. <br /> CPys�ai .�Zt• - d:—_ <br /> S��w ear��4�c��ion nf uw<II in xea'lion BriJ wilh"%." � Sk<Ich ma0 of well Inca�i�n. 4.Wk:LL DEPTH(<ompleted) Date of Comple�bn <br /> � n AJJili�in Name � i"'�� '�� ft. T,�.vI�+.7 <br /> _l ' _ ` _ti _ <br /> � � ; �d�ii���d�$ �fi1Z0! s <br /> M - � - �- -I- - E i❑c�nir�„��i aOree.r�x �❑n��.�o io❑��e <br /> � , -�' � ni�Kk r+�mne. <br /> a ` 2OHi�1lnwn�J SOAir 8❑B�red 11❑ <br /> _ _ _ '' _� ;fl�. � J� 6�1NIed 9❑Y��wet Au`ef <br /> ' ' ' � I l01 Num�er 6. USE <br /> '_1_ ' __'' _- '__'-' � �[ <br /> � � S � <br /> 1 7 II�Jlhimeslic a�Yuhlic SuOV�Y ��Induslry <br /> r--1 eri.T�—�—� a❑trr�eor��� s❑m����co�i aOc�mme�c�.� <br /> 7. FORMATION LO(: ��p�pH HARISNl:SS Ot' F�HOM TO <br /> i[)XMATIUN JOTrst Well 6❑Air('��ndili��nin� 9❑ <br /> 7.CASING HEIGHT:ACove/Below HOLE DIAM <br /> (S7�ti. },� � � �t+ I�Black 40ThreadrU <br /> Yi� �? � <br /> ��c.i�. s❑woiara s�.m« # n. <br /> G�' � �ra0� �3.,�� �� �� �� �❑Plastic a�V o.�ve snoe+ Vm_ No� <br /> �n.to�fl. WeiBh� Ibf./ft. —in.lo_fl. <br /> � � � � ��� in.to ft. weiBht Ibs.�fl. —in.to_ft. <br /> m.to h. wzlRm �na.�h. in.a_ft. <br /> s�� f �� � r/��}_ ��� �� B. SCRk:EN�'� bff1H r open ole <br /> � �v�r pVii from fl.�o tt. <br /> Make <br /> t+`+� 11i'E � 'V +�'� TY7< �Y�iiiiie� V Y� Dia. <br /> �vv y,' <br /> Slot/Gauze � Lmgth « <br /> F'ITTINGS: <br /> �,yri.�1 / � O�� � � �t� Sel between ��� Tt.and �� � fl. <br /> � iU ♦ ( <br /> _ ft.and (1. <br /> �raisli' cl�ry br�n �sd 2 t 5 �,�Li "'°' " <br /> 9. STATIC WATk;R LEVF;L <br /> — — 7� yy��, � <br /> llLlrelnw ❑ahnve Date Measured ���� � <br /> land surface <br /> i 10.PUMYING LF:VEL(below land su�(ace) [y <br /> �� ft.af�er � hrs.pumpin6 �Y g.p.m. <br /> ft.a(ter hrs.pumping g.p.m. <br /> I1y.^V�(F�:LLHEAUCOMNLk:TION <br /> �►LJv��i�•sz�a,v�.•, zOea:emeo�orr:r� �On�ira��ia�•an���r <br /> praJe <br /> 17. Well grouted? <br /> �Yex ❑No Cu.Yds. <br /> I�Neut('emi•nt 2�Bent��nite �❑ <br /> Depth: lrom � � (t.to -�f1. <br /> from �+/ ft.to f�. <br /> IJ. Nearest sources of possible conlamination <br /> leet dircction type <br /> well disinfected upon complet�on? Vesn Ni,❑ <br /> 10. PUMP <br /> i oa,�,�,,.���, 7%2618 3 <br /> ❑�o���_,.,��a <br /> Manuf�cturcl{Y,N�ame 5,���s ���•� <br /> Model�eT' �S �~.• HY.�J`4 Volis <br /> Length of drop pipe "� ti.capacilY B.p.m. <br /> Material qo(,�dro, p D�oe <br /> Type: ALJSunmercinle ��L.S.Turbine S�Reclprocaling � <br /> l�le� 40C'rnlriNgal 6❑ <br /> 16. wATERwELLCONTRACTORSCERTIFICATION <br /> 'fTis well was drilled under my jurisdiction and Ihit reDorl is tru<to <br /> the best o(my knowledge and belief. <br /> �Bu a � • L/crnx N s <br /> Ute a tecond aheet.fI nerded. - <br /> I5. NF�.MANKS.F'LlVATION,SOUItC't;OlUATA,eIt. �� 1�� � x,y+�, ��� � g��q���]"('Ji q�– �9�I <br /> „LA.l LPV lAi7C:L ewi2 <br /> Signed Date <br /> Authorixed Represenlative <br /> � <br /> �jl� ��� Date�� <br /> me of DrJlu <br /> �ac�a co�� " �, � 1 � �� 5/74 30M <br /> � ('�� 7/76 30M <br /> 7/78 30M <br />