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STATE OF MINNESOTA DEPARTMENT OF HEALTH 1. A, WATER WELL RECORD MlNNESOTA UN19UE WELL NO. �� . � County ame a ��'�. ~ r,�-��i,.>� Mianeso(a Statrtes/56A.0J-.08 /�Wate'Sarn e Township Name� ownship Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Date ot Completion �T. �.t�i 31'._; J..�.��k a �.'� W e._•{ J�� .W ;�i-;,/ c./l.� ft. �,-'t r _ . Nu ell Location or Distance from Road Intersection. S.DRILLING METHOD � � ❑CableTool O Reverse ❑Driven ❑pug ��`.? }'.lf�� 7..e3SIt?� i Ul1C)� I�i:LI1TT. � ow exact location d well in sectiortgrid wi "X." Sketch map of well locatan. ❑HollowNod ❑Air ❑Bortd ❑ N i Addi[ion Name a�l Ro[ary ❑Jetttd ❑Power�Auger � '_r' ti_ _ �.","�-..�-^ �" i � ;� � 6.DRILLING FLUID � h�' � I I i 1 � --�' '�- - �_ Black Number �,". W � � � E t� 7. USE � �omestic ❑Monitoring ❑Heat Pump _1_ _1_ _'_ S' � JP I � � � Lot Number ' ��- ❑Irrigation �O Public ❑Industry h mi. � � � � > �Test Well {7 Municipal ❑Commercial --�- - - -r'- � ❑AirConditioning ❑ 1 ��,�1e'—� 8.CASING �(� �HOLE DIAM. 2.PROPERTY OWNER'S NAME Mailing Address if diffe�ent than property address r HEI�:�ove/�lo� �� �Q Black �'Q'hreaded indicated above. Surtace (c. �,�3.C:.� t..'�L'.1.ICla O Galv. O Weldcd F'�-3 ��"�Z t�� t"�� ❑plastic Drive Shce? Yes�' No— f...,.. � ,�j �y 1�c: , �7� �p '�"'' • �i:?.5 < �.�^^��t �...�k in.to�__6 St�ft. Weight �Ibs./fL �n. toi..-t-.1t. 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.ro (t. Weight Ibs./ft. �n. to�t. FORMATION in.to tL Weigh[ Ibs./tt. —in. to�t. L..Z.ii�% �� = 9.SCREEN Or�open hole J�u-y�i� (rom ft.to. tt. Make J, �txl�C.i �:.i �s�U Type .fi`a�"�1" j �_�r' °-itE�E'�� Diam. ,t'� ry 1 SIoVGauze 1� Length � ` 36� L�.� FITTINGS: �,yZ1T1' J14'TC7 L{_r c��tr' Set between ft.and it. � t t 10.,��'ATIC WATER LEVFL t' t, � j[ L.�LGt[' i� l�rl� /:t S �7-�'�'7�, j (L O'bebw ❑above Da[e Measured land surface ��" I t. PUMPING LEVEL(below land surfare) �.1CIy 'ri i.� ��3 b �� ft.a(ter '� hrs.pumping "t� g.p.m. (t.after hrs.pumping g.p.m. ``M31�'`7"'��r`r� '�a '��= 12. HEAD WELL COMPLETION �]Pitless adapter manufacturer ��1 �� 'f��'-'� Model ❑Basement oftxt �lt leas[12"above gruund ❑Plastic casing protection 1�3.WELLGROUTED? ]}SYes ❑No ❑Neat Cement ❑Bentonite � �'��-�43t g=��;'b-�112 Grout material from m tt.cu.yds. '� 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION fee[ direc[ion � type _ Well disinfected upon completion? � �es ❑No - 15. P[JMP Date installed ��j�"�`-s ❑Not installtd Manufacwrer's name �-�' *��1��- Model number HP �4 ��iVolts •--%�' Length of drop pipe �t��• tL Capacity �L g.p.m. MatEtial of drop pipe -�-H U'>>i V tr Type:�]Submersible ❑L.S.Turbine L7 Reciprocating OJet ❑Centri(ugal L] 16. ABANDONED WELLS , Unused well on property? O Yes ❑]�o Use a serond sheet,iJ needed `.xaled O Permanent ❑ Temporary ❑ Nol sealed 17. REMARKS,ELEVATION,SOURCE OF DATA,etc. 18.WATER WELL CONTRACTOR CERTIFICATION This well was drilled under my jurisdic[ion and this report is true to the best of my knowledge and beliet. 't�.i�v ��`��Di;i,r�, tt�'"L,r. �Ili�i CG.� IItiC:. :�11�� 7 Lrcensee Business Name License No. Addressl:�-.'i'-C1 �.'i..C.��:.-�`✓ � i L�L`}S.? �1J_,flt1. :.t;.��.3ltJ s �:��'.. Signed9'"��_.�_ �-�� Datr �_'try��`� Au�ortzed Representattue �� F'4.,�.��.C'�«i 1�.�� Date Z''fi"�..sy.�t Name oJDriller ,... :-., .� 5/74 30M �.. }_ �,... ,; �(' 's� 7/76 30M LOC<;L_ COPY `r , ; `J HE•01205-03(Rev.9/88) ziez io�M