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WELL�OCA�IQpJ MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> � CountyName ln WELL AND BORING RECORD , � � 4 31 <br /> �� Minnesota Statutes Chapter f03! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> -7 ry ) y ft. t' <br /> �C7�ZG ��I 6.3 ��La. �lF���F!I�i X G�t:f �"JV"'�� <br /> � House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> �r _,+. ❑ Cable Tool O Driven ❑ Dug <br /> L��:t CiC�17I2� .,3C� �. �d ���� ��• �'=�'f' ❑ Auger E5 Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing propeRy lines, <br /> roads and buildings. DRILLING FLUID <br /> N ^ �TitCr:11�E.? <br /> _i i i i_ �.../1.-.�. <br /> i -i- -i- -i <br /> J�,/� USE O Monitonng ❑ Heating/Cooling <br /> i i i � 1, � [?:Domestic ❑ Community PWS ❑ Industry/Commercial <br /> _i_ _�_ _�_ _i_ F G. M1. � ❑ Irngation <br /> w � � � � E X w�� . �'� ❑ Test Well � Noncommunity PWS ❑ Remedial <br /> i i i i T <br /> `� ❑ Dewatering ❑ <br /> i i i -� ,�'M,ie � �'� CASING Drive Shoe? O Yes �o HOLE DIAM. <br /> _� i _L_ _�_ � � ❑ Steel ❑ Threaded ❑ Welded <br /> i -i- i i <br /> !� d{Plastic ❑ <br /> s <br /> �1 Mlle--i <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME a in.ro �t''� ft. Ibs./n. f ���o `�, <br /> Tc�rty �i.c+en C���n�� <br /> in.to ft. Ibs.Rt. �,�.�p���. <br /> Property owners mailing address if different than well location address indicated above. in.to ft. Ibs./R. _in.to_fl. <br /> SCREEN___���� OPEN HOLE <br /> Make from ft.to ft. <br /> Type � £`S'-�'' �P�1 Diam. �.n <br /> SIoVGauze �t}/��J Length t�{ <br /> Setbetween ` �� R.and ��—k. FITTINGS: G� �i ��.� <br /> STATIC W/�TER LEVEL ��,y��y <br /> WELL OWNER'S NAME �� tt. D�betow ❑ above land surface Date measured j� � <br /> PUMPING LEVEL(below land surface) <br /> Welt owner's mailing address if ditterent than property owner's address indicated above. R. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION ��i����, <br /> Q�itless adapter manufacturer Model <br /> ❑ Casing Protection q�2 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ❑�.f'es ❑ No <br /> HARDNESS OF Grout Material ❑ Neat cement Bentonite ❑ Concrete ❑ High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � � <br /> from to �%U ft. � ❑ yds. Cp�bags <br /> t t from to ft. ❑ ds. ❑ ba s <br /> 7'ap Sc�i�.,lCl�-�y Cs��' a�. � ��!t_•' Y 9 <br /> from to ft. ❑ yds. ❑ bags <br /> NEAR j KNOWN SOURCE OF CONTAMINATION . r ' <br /> �lay k7��dV@Z Dc�}C Gt3.E" :� �t.+�3 ��4}� i teet ����� � direction �E � 4 tYPe <br /> Well disinfected upon completion? LY Yes ❑ No <br /> `-�.�ci21C'f f''li1E? �'C3VuTi :.i ��l% L(.-(�T <br /> PUMP C <br /> ❑ Not installed Date iostalletl �_�_�v ._ � <br /> �311Gt��. �j� 4 L�)�f ���� Manufacturer's name __ <br /> Modelnumber a HP �� Volts ��f! <br /> Length of drop pipe �u�i R. Capacity '�� g.p.m. <br /> Pressure Tank Capacity (�i=�'y�ZL")j'1 �(��;d� <br /> Type: C�y"^ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS / <br /> Dces property have any not in use and not sealed well(s)? ❑ Yes CJ 1V6 <br /> VARIANCE <br /> � <br /> Was a variance granted from the MDH for this well? ❑ Yes �No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> � :`��i�}� �°��.1r ��.� ��).� .LIV�.. G 1�J i <br /> Licensee Business Name Lic.or Reg.No. <br /> a �-- <br /> � ' '� l <br /> Authorized Representative Signature Date <br /> �:t 1t1�'r� hk:�;�4 <br /> �'` (''� t � � Name ol Driller Date � <br /> �.-� • .. � t-"�'" °"F "' " L_i' �� � HE-01205-05(Rev.t/95) � <br /> � <br /> i <br />