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STATE OF'MINNESOTA UEPARTMENT OF HEAL'1'H <br /> �.tiocnTioN oF ws�� WATER WELL RECORD �ti��^'^'r,so�A c,��reuF�iti�ezc n�a ������ <br /> County vame - <br /> �pny'1R�7'y� blinnrsola Sfatu(es]SFiA.OI-.08 lor R'ulr�r Sampfe <br /> ..--a <br /> Township Namr Township Number Kange Number Srction No. Fraclion 4. WF.U.DEP"PH fcomplet�d� Uate o(Completion <br /> Uro¢�o 117N s ?.3i�i w IO �w�"� `3a�e '" 216 << 2j7/�1 <br /> Numerical Street Address and City of Well Location or Distance from Road Intersec[ion. 5. DNII,I.ING METHOD <br /> 1�� yt���� ��� ❑Cablc"lix�l ❑Reverse ❑Uriven O Uug <br /> «�� <br /> Show exact la'aGon of H�ell in section grid with"X." tikeich map o(wcll location. ❑Hollow-I:ud � ❑Air ❑Rored ❑ � <br /> N <br /> � i i Addition'�'ame �Nutary ❑Jettrci ❑Power Augcr <br /> '_r_'y_ _1 _1_ <br /> i M li. URI_�LI,s1�!`G E���A .. <br /> i�ii iJc <br /> � � � � Block Numbcr <br /> '-�- --- - �- 7. 1:5E <br /> W � i � E <br /> � � �)omestic � ❑Momtoring ❑Heat Pump <br /> _1_ __ __ __ <br /> I i ' I,ot Number `� ❑Irrigatioo � �❑Public� ❑Industn� <br /> f-mi. <br /> � i ❑'fest Well ❑Municipal ❑Commercial <br /> --�- �- -� -r' I ❑Air Condi[ioning ❑— <br /> � 1 <br /> � � m-��,_� 8. CASING HOLE DIAM. <br /> 'L.PROPERTY OWNEH'S NAME Mailin Address if differen[[han ro ert�address HEIGH"I':Above/kielow <br /> B P P � ❑Black ❑Threaded <br /> indicared ubo��e. Surtace ft. " <br /> ❑Gak. ❑Welded <br /> ��k J(X� �y25 �1,� 1I�s �Plastic � Drive tihce? Yes_ No� <br /> ���a,raa� 1'�i7 �J7� � �� in.to ���(I. Weigh[ �sj� Ibs./(1. ��n. tu!➢f. <br /> 3. FORMATION LOG COIAK HARUtiESS Ot Fk��M TU in.m —ft. Weight Ibs./(t. _�n. tu-�t. <br /> FUNMA"IIUti <br /> �- in.tu tt. Weight IbsJft. �n. to�t. <br /> �y ��1 Q � 9. SCKEEN Or�open hole <br /> �,�� trom ft.to. _ - (t. <br /> Makc ,{2�, y,�, <br /> �'�r$� �ILV�K�- ... V :JO TYPe� Diani. `Y.iU•G�.L. <br /> ��� tilov(;auzc �v1�iVL , Length 5 ft __ <br /> t7��d ����' i�D :7Z SP L11 t�.and Zl� ft. �'�dt ��(;ti� <br /> �, Set betwe . <br /> ����� 8��p�� ��� 10. STA"I'IC�EK LEVEL <br /> arVlRa �2 -_�� CL�beluw ❑aboce Date Measured�f��_7 f�� <br /> land sur(acc <br /> Il. PUMPItiG LEVF.L ilx•lou�land surface� <br /> ��+�� � �� �� (t.a(ter _hrs.pumping ��� g.p.m. <br /> t_ (t.a(ter hrs.pumping g.V�m. <br /> Ci�yl�a� �� �� ��� 12. HEAU.WF:LL C:OMPLE'I'ION <br /> $��� �Pitless adapter mnnufacturer— _ �tr�dcl — <br /> C�� �� ��� �`��� �O Basement,o((set �L]At least 12"above grnund <br /> ❑Plastic casinK protectiun <br /> 13. WELL GROUTEU? �II Yrs ❑Nu <br /> San�il vel Yellaw 202 216 <br /> � �M1eat�ement ❑Bentonite ❑ --- <br /> Grout m32erial #rom�__�o-��ft.cu.yds. _ <br /> In_ NF:AHEST SOURCES OF POSSIBLE CONTAMINA7'ION <br /> (eel direrlion type <br /> Well disin(ect�d up�m mmple�iun? �Yes ❑No <br /> I5. Nl"MN <br /> Uate installed �,���� ❑tiot installed <br /> Manufacturer's name ���� <br /> « Model ny�Snber — HP 3/4 Volts 23a <br /> Length u(drop pip.. �� (L Capacity �-a H.p.m. <br /> Material o(drop pipe �� � <br /> Type: �Submersible ❑L.S.Turbine ❑Recipraating <br /> ❑Jet ❑Centri(ugal {7 <br /> 16. ABANDONED WE?LLS <br /> Unused well on property? ]QYes ❑No <br /> L�se a srrond sheet,i/needed Scaled � Permanent ❑ 9�emporary ❑ Not sealed <br /> 17. REMARKS,ELEVATION,SOURCE OF DA"I'A,etc. <br /> � 18.WATER WELL CON"1'RAC7'OR CEKTIFICATION <br /> 7'his well was drilied under my jurisdictiun and this report is Irue to the best of my <br /> knowlcdge and belie(. <br /> St�vQ.ns well llrillirx� Co � Tnc z7194 <br /> Licene'ee Business Name /ieensr No. <br /> �24a A' • 12 v+Tes Plain :�N 55359 <br /> A ress <br /> Signed <br /> � � � Date ������� <br /> ��j��� *i_ Autliortzed ltepresenta(iue <br /> 1r1LIS.0 iS.L�`'�'! Date ��12�g1 <br /> Name o(Driller <br /> LOCAL COPY ��� .� � � ii�s oM <br /> HE-01205-03(Rev.9/88) ziez ionn <br />