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STATt Ok�MINNI�:S()TA UE'.YANTMF:NT OI�Nk:ALTH <br /> I L(�l ATI()N UI WF LL FI/NNFSOiA UN/QUF.WEI.L NO. <br /> ������r����••�/� WATERWELLRECORO ,w„osomk �� tl �� � '� <br /> ' ����^��A . Min eaSralurnlSlrA.rll..r1M ,n v a�r �S` ��" <br /> T�iwnshlp Nnme Tnw�sh�p Numher Nan{c Num�er $�cilnn Nn. I�raiti��n 3. YROYk;RTY OWNF:R'S NAMF; <br /> r�r��Q Z�� �Sr '^"./ b W �� .�i%.i 47� at� s+3f'�i��7. .Ju:��i� '..._...... - . <br /> I)Islance+nd Ilkeclum trum N�u�Intersecli��ns��r Slrcel AJJress and C'lly of W�II Loc�liun Addra6t � "�"h� � <br /> ,Rw?.Q` �2l�QIC�@2'�'�f T'f 1(.-\..- `\� _ <br /> SM.w ea�c�I��crc�an of well in vec�iun rriJ wi�h"%." Sketch map of weil Incation. 4.'.V1kLL➢6Ei'H wn '� <br /> : N tc v�e�ea} ...�___. . .... . o.unrcomp�.��o� , :� <br /> AJJili��n Name '�%i J ,i��I.�•L 3 G V' ���+.t"'a..� r <br /> _L_ _ _ ' `_ _ _ h. <br /> � � � 5. <br /> N -- - �- -I- - E iOc�ni<����d oOe�..� �❑n,�.�o io�n�e <br /> i i { � tll��ck Num�tt <br /> ` EOyHollnwrnJ s❑�o- sOe��ed ii❑ � <br /> _ - ' '- _� �� 7i-1 H"�'rY b❑letted 9�Ynwer Au`er <br /> ' ' ' � � Lot Numher 6. USE <br /> '_i_ ' __'_ _ ''_'__ �y <br /> iL7o��mr���� a❑v�nu�s�vv�r ��i�e�:�ry <br /> $ <br /> r-1 miis 2Otr,cg�r��� sOnw��c�p,i eOc�mmr,c�,i <br /> l. kORMATIONLO(: ��n�nµ HAHItNh:SSOt FH�M TO <br /> F�()NMATIUN l�Tr��Wrll 6OAir('i�ndili�nin� 9❑ <br /> 7.CASING HEICHT:AEove/Below HOLE DIAM <br /> �'��..'�I7il '..+Z�,� ��'�f�13 ..i:3�t � s��. �mui��k aC�nrr,a<a <br /> iOc,i�. s❑wetara s��r,« n. <br /> v�t�� Z.t�� ..�Q�ir Ga �VG7 l�PlastiC p❑ DriveShoe? Y<�_ No_ <br /> L �m.ro ��� !t. WeiQht Iba./fl. -fn.to_ft. <br /> 1.�.$�' � FiIY'1+� �,€Z'"b� x rL7��+ i�V 1� ��.w n. we�ene ms.�r�. —�o.�o_tt. <br /> �n.[o tt. wef¢n� �b:./R. _+n.�o_ft. <br /> `:�.;'.'? ��z?"+'1:�i7; .�u4'�� 1� �.� e m���Nai C1�2A�iQl1 r.om�� m� n.�o r�. <br /> �ta�nl�ss �steel � <br /> TYP� Dia. <br /> Slot/Geuze � � a Len th "� � <br /> 8 <br /> F7TTINGS: <br /> Setbetween n.,�a (1. <br /> n.a�a n. <br /> ,3 �:'�s �'�'��'fiA:-:�f3i1 <br /> 9.STATIC WATk:R LEVEL <br /> '_ __ _ "-"� (I.�trel��w ❑ahove Dale Measured ` �� <br /> land surfatt <br /> lo. YUMYINGLF;VEL(belowlanJsurface) �j <br /> fl.aller hrs.Oumpin6 '"� g.p.m. <br /> ft.af�er hrs.pumPin6 B.p.m. <br /> II.WF:LLHk;AUCOMVLtT10N <br /> ��itless adspter,manufac[urer model <br /> z❑eas�m��i orrsr� �O ei ie.s��z�� ..e g.me <br /> 12.WELLGROUTED? �- <br /> I_.JRe� ❑No <br /> I�Neal('emcnt 2�nt�inite 3❑ <br /> Grnut materiel fr�m ft..Cu.YCs. <br /> 13.NEAREST 60URCES OF POSSIBLE CONTAMINATION <br /> feet directlon type <br /> Well disinfected upon comple[�on? Yes� Nn❑ <br /> 10. PUMP <br /> Dale instslled ❑Not fns[slled <br /> h@tx'�'�.(iT' <br /> Manu(sc�ureiY Name <br /> J � <br /> Model Number HP � �I� <br /> Length of drop pipe ��ryft.capacitY B.p.m. <br /> :.�LCB.E <br /> Material o!,.dyroD D�O� <br />.. . 7ype: IL'T'Sunmcrslhlr 7❑L.S.Turbine s❑Reclpn�cnting <br /> l�lel <�C'<ntri(uWl 6❑ <br /> Use a secrond sheet,il needed �6.WATEH wELL CONTRACTOR'S CERTIFICATION <br /> I5.REMARKS.ELEVA170N,SOURCE OF DATA.ecc. <br /> This well was driiled under my jurisdiclion and Ihis report ia true lo <br /> the best of my knowleOge and belief. <br /> i�llk :.�U�lAel" �El1�. 4.0. 1���.�� <br />� Litrnare Buainru Name Llcerue No. <br /> ,�ee,�x `tJX �.��• �"�.0 wCaT��• P� 1�����i <br /> — : <br /> ,� <br /> :�,/�;e'`f ' `,��� ,�r,+/�.�,� <br /> 4 <br /> Sg d l�,���� ��_. � J .� '�Date � <br /> � Authorixed Reprcsenlative - <br /> a�xttl7t"�[Sa i._ �.a��l�e�sw ua�e K/R/��l <br /> �.:�:r�L ���Y � N.m�o�o���a <br /> ,•`, �•" ° ., k',��„ 5l74 30M <br /> - 7/76 30M <br /> , _ _... ..,�. �..'" 7/78 30M <br /> HE-0120.5-01 2/82 10M <br />