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STATE OF MINNESOTA DEPARTMENT OF HEALTH
<br /> � AT�0.N WATER WELL RECORD MINNESOTA UNlQUE WELL NO. �
<br /> County Name , ��(j���
<br /> /f_,k{y„�-i_ ,._2_._� Minneso(a S(afules 156A.0I,08 /or Wafer Sample `J
<br /> Township Name� � Township Number Range Number Section No. Fraction 4. WELL DEPTH Immpletedl Date of Completion
<br /> '_ . � , °' _,.�.r'.E aJ.� � � � �''� / ft. f�' - /Ce �/O
<br /> Nymedeeh3tieEf=�d8tE55-and•City.t�f.Vl�ell.Lacation or Distance from Road Intersection. 5. DRILLING METHOD
<br /> J
<br /> i �{ - J,�� . ❑Cable"lool ❑Reverse p Driven ❑Dug
<br />; <��/ '' !:�._sP r :F'.. � � - ,4+--� .
<br /> ow exact location ot well in section grid with"X." ��� � ��Ske[ch map of well location. ❑Hollow Kod ❑Air ❑Bored ❑
<br /> N
<br /> ._� � _i _1_ Addition Name �Rotary ❑Jettcd ❑Power�Auger
<br /> -� � - �'�� --�� � 6.DRILLING FLUID
<br /> �
<br /> --�- -=- �_ �_ Block Number
<br /> �y � � j E 7. USE
<br /> i
<br /> _1_ _1_ _'_ _ T �1 Domestic ❑Monitonng ❑Heat Pump
<br /> I � ' Lot Number ❑Irrigation ❑Public ❑Industry
<br /> 'f_•mr.
<br /> ' � � � ❑Test Well {]Municipal ❑Commercial
<br /> --�- �- - -r' ❑AirCondiuoning ❑
<br /> i
<br /> �—1 mile� 8.CASING HOLE DIAM.
<br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address HEIGHT:A6ove/Below
<br /> �I Black p,�Threaded
<br /> indicated above. Surtace (i.
<br /> : / �� � � _ ! ❑Galv. ❑Welded
<br /> •�.,. , � ij. ��j/ �} !?�� I�� ,. ;'.:� Drive Shce? Yes�jS,No—
<br /> , _. • � d '°^�, l.'�i��. � . :'..y,'s.�.. ..- _. . . O Plastic ❑
<br /> : ;.�::... �..' , �� _C .,.....-,.._. r= �__!. .� .� � � g ;�.:n � ',d.
<br /> ��, � /,.� .f.r ,. ''A! in.to -? � (�. Wei ht � � Ibs./(t. �in. t �t.
<br /> 3. FORMATfON LOG COLOR FORMATIONF FROM TO in.to (t. Weight IbsJtt. �n. to„iE�e�t.
<br /> in.to (L Weight IbsJft. �n. to—ft.
<br /> � 9.SCREEN Or�open hole
<br /> �' ' ,-. .. j F ,. �� �
<br /> , _ _ .. �. � ....�:... , . �.�� � from�fl.to. ��(l.
<br /> Make
<br /> - . � . .�::.-{ . }'.F{i.:.f � � "3 F'.: �f TYPe Dlam.
<br /> f
<br /> Slot/Gauu Length FITTWGS:
<br /> ' -- ,--�:�. f� � �� � Set between tt.and f[.
<br /> �
<br /> ��� i � . 3 .�10. STATIC WATER LEVEL
<br /> f�r-�_ � _ � �� � f
<br /> ���'�� '� '"r`�f� f L u (t.�below O above Date Measured / l �`at
<br /> land surface
<br /> . � - 1l. PUMPING L6VEL(below land sur(ace)
<br /> r ' : i- r1� td �
<br /> � ' ti` � �"'"i; ([.a(ter `� hrs.pumping �',�!� g.p.m.
<br /> (t.a(ter hrs.pumping g.p.m.
<br /> 12. HEAD WELL COMPLETION .,r. .,.,�,,,,.
<br /> �1Pillessadapter manufacturer {��'"-'�"�"��"-'"�- Model -J- `/
<br /> 'O Basement offset ❑A[least 12"above ground
<br /> ❑Plastic casing pro[ection
<br /> 1'3. WELL GROUTED? y,,,xes ❑No �
<br /> ❑Neat Cement �entonite ❑
<br /> . . ._,_ Grout material (rom ��to_.�—ft.cu.yds.
<br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION
<br /> � '
<br /> ��`� -�-`feet "'"J direction -�<'�x�-�^- r✓�+t'`j' -,_- �YP�
<br /> �.
<br /> Well disinfected upon compietion? �Yes ❑No
<br /> 15. NUMP
<br /> �..
<br /> DE C 1, 7 ,S,t7e�►.�l Date installed � ' � d// �� ❑Not installed
<br /> Manufacturer's name ���•�'"e..r�.�.�-�+.. d"*7 , ..,E.,.�.
<br /> Model num6er -3 f � � /L4--� HP_�y Volts���
<br /> I.ength of drop pipe ��!j / ft. Capacity ,�•-,fl g.p.m.
<br /> Material o(drop pipe � .-SC
<br /> Type:7GLSubmersible� O L.S.Turbine Ll Reciprocating
<br /> �Jet ❑Centritugal C7
<br /> l6. ABAIVDONED WELLS
<br /> Unused well on property? ❑Yes �'No
<br /> Use a semnd sheef,if needed � Sealcd ❑ Permanent ❑ Temporary ❑ Not sealed
<br /> 17. REMARKS,ELEVATION,SOURCE OF DATA,etc.
<br /> • 18. WATER WELL CONTRACTOR CERTIFICATION
<br /> This well was drilled under my jurisdiction and this report is vue to Ihe best ot my
<br /> knowledge and belief.
<br /> J c� �'e� ..�1� ;.> l � t� a l �'
<br /> Licensee Business Name, /. L+cerrse No.
<br /> � Address `j � ✓ �. : 1�;✓� _.� r:%..-n-
<br /> Signed .�-t . _ .,f�� Da[e` . . . ��.�
<br /> � Authortzed Representa[lue
<br /> � -9 !a t %`
<br /> �'.t `�1—f i.����-5�'"�,..-->. r Date _I f il
<br /> Name oJDriller
<br /> LOCAL COPY O�O 61� 5/7430M
<br /> 7/76 30M
<br /> HE-01205-03(Rev.9/88) �i�e 3°M
<br /> ziez�a.n
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