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STATF.Oh MINN1�:5()TA UF�.PANTMtNT01�Mk:ALTH <br /> I. L(�('ATI()N UI-WV-LL ���NNFSOTA UNIQUE WE/.L NO. �,., <br /> c�����rN,��.• WATER WELL RECORD � `� �.,� J� r^ �� <br /> a�� � . . IorWaferSample �, �./ �i�;�, '`� <br /> Minn �a SteNfet/SFA.lil�.11N <br /> T��wna�ip Name T�wnsh�p Numher Nan�e Numher y���{nn Nn. I�raiti�in J. YROPk;RTY OWNER5 NAMF: <br /> �� - ��lr� S� 6�E W �V�v. , �S/ Tiw � . . }f� ��G....'�:4Y <br /> I>Islani'e and ItKecl�un(rum k�uJ Inlers<tli��ns��r 51rce1 AJJreu anJ(l�y of Wrll L�ic��iun Addrcss ��� �� ��� <br /> 1��$�Lacs eut �'.�. <br /> S�ow es�cl I�ic�lion of wsll in xec�iun priJ wilh"X." Skelc�map of well I�caiiun. a. WlLL DEPTH(<ompleted) Date of Completion <br /> M +} �}g� <br /> �JJili��nName � f�;��'�"'(,}{j :� <br /> -�- - � - '---� - �.�rJ n. <br /> � C s i0c�nirm�d a❑e��.� ��nd.�� ioQo�e <br /> W -' - _�'y i-�- - L bl�rck Numhtt <br /> is ' � 2�Hnllnwr��d S�Air 8❑Bnred I1��� � <br /> ' - - '- ' ;}e1L. J[�"��rY 6❑Jel�ed 9❑Yower AULer <br /> � � l <br /> Lol Numhcr 6. USE <br /> _'i_ ' __'' _' ___,__ <br /> 1���meslic a�Yu Alic SuOPIy Y�Induslry <br /> S <br /> F-1 wiZ� 7�Irrig��i�in S�Municipai e�C'nmmercial <br /> 3. FORMATIONLO(: ��p�pµ HAItI)Nh�SSOF 4'ROM TO <br /> InNMAI'IUN J❑Tr�t Well 60Air('nndi�ionin� I 9❑ <br /> 7. CASING HEIGHT:A�ove/Below HOLE UTAM <br /> �Yii�� elay & �rav�t. a IS ��b�+ck eOThreadeJ <br /> 3❑(:alv. S�Welded Sunc�e f(. <br /> q���j� ['�H�V ��, � �j ,l�las[ic �•� ���e Shoe? Ye�_ No� <br /> `i'•+ � fn.lo ��� fl. Weight ���� Ibf./fl. ��fn.1���(t. <br /> ��yp� e�� �� �� �n.lo fl. WeiBh� IM1s./f�. -�n.Io_(t. <br /> n.to fl. WeiRh! Ibs./fl. in.lo_(t. <br /> 'L1..�a wj gyy � �� �� 1'�}G 8.SCRF:EN ropen ole . <br /> Y�.i.�17'�L+ �.acs� .L,�1 <br /> Make ��SQ� �rom tl.to ft. <br /> L =a� �,`( sva. oia. �itA <br /> V�ii� �y � �}i'� I '(Qr TYC� <br /> ataf ✓� = <br /> SbtJGauze L� � Lengt� ��41 <br /> F'ITTINGS: I <br /> Set between �,� ft.an0 1 SS <br /> ft.anA ft. <br /> 9.STATIC WATlR LEVEI, <br /> �g f1.�hNi�w ❑aM1ovr Dat<Measured �`S <br />. � -- - lane•��ra�e <br /> 10.PUMYING LEVEL(below land surface) <br /> (t.af�er hn.pum0��6 6�F�m� <br /> ft.aftet hrs.pumping g.p.m. <br /> 11.Wk:LLHEAUCOMYLk:TION <br /> �[�Pitless edap[er,manutecturer model <br /> I�8asemen�of(se� J A��eaat 12"above greAe <br /> 12.WELL GROUTED? <br /> �ex ❑No <br /> li_yye�IC'emi•nl 3�Ben���ni�e 3❑ I <br /> � <br /> Grout material from ft..Cu.Yds. <br /> I�N�EARE$T SOURCES OF POSSIBLE CONTAMINATION <br /> �� feet direction IYV� <br /> wen m:��r«��a�Po��ompi�c�o�t vr:❑�N„❑ '. <br /> 14. PUMP <br /> Dale inst�lled ❑No�ins�alled <br /> Manufac�uretY Name ��„� <br /> Model Number HP �•0' Volts �,�,_ <br /> Length of drop pipe �� fl.capacilY �� 8.p.m. <br /> ' Malerial of droD D�pe �$x r�� <br /> Tyve: 145unmer:ihle ��L.S.Turbine sOReclpri�caling <br /> A <br /> 7❑Jel 4❑C'enlrifugal 6� <br /> Use a secand sheet.ilneedad 16.WATER WEI.L CONTRACTOR'SCERTIFICATION <br /> 15.REMARKS.ELEVATION,SOURCE OF DATA.etc. <br /> This well was drilled un0er my jurisdiction and tMs report ia true to <br /> the best of my knowledge and belief. <br /> n <br /> ictnxr uN eu Namt t o. <br /> ,,�..�,�+�{� � 12 6�3 �a�al� $�.aa.ia, :�3 <br /> Signed Dat< ��� <br /> Authorixed ReDresentative <br /> ' R�i�p .�0�lIlSt1T1 �p-QF—�? <br /> n.�� <br /> LOCAL �i�.yt� .1 s`A +� f? �"'� NameofDrillm 5!l430M <br /> i t � <br /> 7/76 30M <br /> � .,.. .. -�. .. 7/7830M <br /> HE-01205-01 2/82 10M <br />