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<br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO.
<br /> CountyName WELL RECORD 5 613 5 8
<br /> �'��=�''"'''3� Minnesota Statutes Chapter f031
<br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
<br /> n.
<br /> :,� + i^ ��. �. �. '` - 1: -
<br /> Numerical Street Address and City of Well Location or Fire Number DRILUNG METHOD
<br /> t _ ❑ Cable Tool ❑ Driven ❑ Dug
<br /> :.{ � � i_C�ii"i�'_i v'r 3�:t:: �Ji. �`f. 1i7�'i ,r,C-� t,i i. ❑ Auger ❑ Rotary ❑Jetted
<br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑
<br /> Shoy+mg property lines,
<br /> N /roads and buildings. DRILLING FLUID
<br /> I i � ' `��i
<br /> _'r"y_ _1 _1_
<br /> � �
<br /> i � � i � ,USE q Domestic ❑ Monitoring � Heating/Cooling
<br /> �-�- --- - �- ❑ Industry/Commercial
<br /> yy � ; i , E ❑ Irriga[ion ❑ Public
<br /> ' T ❑ Test Well ❑ Dewatering � Remedial
<br /> _1_ _1_ _'_ S' I ❑
<br /> I ! ' �
<br /> � , f"""� ``L CASING Drive Shoe? ❑ Yes � No HOLE DIAM.
<br /> --;- �' - -�' I y�� kk ❑ Steel ❑ Threaded ❑ Welded
<br /> 1 ���'� �`Plastic ❑
<br /> �-I milr� -^'�
<br /> CASING DIAMETER WEIGHT
<br /> PROPEFTY OWNER'S NAME � '
<br /> ' . � in.to 1`-'-%ft. :�-{.3�t..._.''� Ibs./R. � %ie�t -
<br /> o ��t.
<br /> ;� '1\� 1,.1{. ::: .. in.to fl. Ibs./ft. �
<br /> -T��to�r�f.t.
<br /> Mailing address if different than property address indicated above. in.to ft. Ibs./ft. in.to ft.
<br /> � i� I �`I��,, : � L,, ;R`, .�, SCREEN OPEN HOLE
<br /> � y� � - Make lkii l_l Y� 7Y'+ ::.�;", from R.to tt.
<br /> f�. '�'l; .� , �.:. :. .. � . .
<br /> ;. . ,..; .. �.;
<br /> TYPe .,1-��-t��-s�`--,—.k Diam. ;t3
<br /> SIOUGauze Length " �
<br /> Set between �:'�:�� � tt.and �j.� ft. FITTINGS:
<br /> HARDNESS OF STATIC WATER LEVEL
<br /> GEOLOGICAL MATERIALS COLOR FROM TO ?; `r ft. 0� elow ❑ above land surtace Date measured �'
<br /> MATERIAL � e- .-; ".
<br /> PUMPtNG LEVEL(below land surface)
<br /> � �.��.��.�'. c+ :��:ti�-�.i) �. ' ° ���. . t ft. after hrs.pumping g.p.m.
<br /> WELL HEAD COMPLETION
<br /> ,,, .. i:�la� �� --,�_i":.- ��.
<br /> ,'�,1^,�.i ��..(;� '��� �C] Pitlessadaptermanufacturer Model
<br /> ❑ Casing Protection [] 12 in.above grade
<br /> GROUTING INFORMATION
<br /> Well grouted? ❑,Yes ❑ No
<br /> Grout Material ❑ Neat cement ❑ Bentonite
<br /> from � to ' ft. ❑ yds. Q,bags �
<br /> from to ft. ❑ yds. ❑ bags
<br /> from to ft. ❑ yds. ❑ bags
<br /> NEARE$.�KNOWN SOURCE OF CONTAMINATION
<br /> �-��) ° teet ��,�e'yJ��;' direclion ,,�zs"'Li T;l'ryPe
<br /> Well disinfected upon completion? �Yes ❑ No -�—T-��
<br /> " PUMP
<br /> ❑ Not installed Date installed '�a�_��j__��.��-
<br /> Manufacturer'sname _��;.£,
<br /> Model number Z��r.�>� `7 HP�_ Volts L_�i-�
<br /> Length of drop pipe '�i� 4 ft. Capacity '�� g,p.m.
<br /> Pressure Tank Capacity �
<br /> Type: ❑ Submersible �]�L.�.�Turbine�❑ eciprocating ❑ Jet ❑
<br /> ABANDONED WELLS �
<br /> Dces property have any not in use and not sealed well(s)? O Yes C�,No
<br /> WELL CONTRACTOR CERTIFICATION
<br /> - � This well was drilled under my supervision and in accordance with Minnesota Fules,Chapter 4725. �
<br /> The information contained in this report is true to the best of my knowledge.
<br /> Useasecondsheet,iineeded i-z� t'� E .. . { �.�.-. t�s-,i�., i ...�.i�.,1 '{.; _ , � ..!iu:.`, ,. � � ,
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name . Lic.or Reg.No.
<br /> � � i . � j ,Y- ._�'� -
<br /> ••—/� � %J
<br /> y�� � � . e..-�'-� :
<br /> Authonzed Representahve Srgnature Date f
<br /> ! ,...::,�... .� ,�, ,
<br /> � .1 . ,.`t.__ .. . . ..
<br /> Name of Driller Date
<br /> LOCAL COPY 5 613 5 8 HE-01205-04(Rev.5/92)
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