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STATE OP MMNESO"fA UEPARTMENT OF HEALTH <br /> I.LOCATION F WELL WATER WELL RECORD 'ti����N@'SOTA UN/QUE WELL NO. �7�3 f 4 <br /> County Name �or Wa[rr Sample <br /> �}��� hlinnesola S1a(ufes 156A.01�.08 <br /> __,,.r <br /> Township Name Township Number Range Number Section No. Fraction 4.WELL DENTH(compleledl Date of Completion <br /> Ur�o 11'7et s 23W w ? S6�''NE ''S��' $205�. 05/13/91 <br /> Numerical S[ree[Address and City of Well Location or Distance from Road Intersection. 5. DRILLING METHOD � <br /> 1496 Park Urive 1"J�JWii� NAt 55364 o Cable"lool ❑Reverse ❑Driven ❑Dug r`� <br /> Show exact location o(well in section grid with"X." Sketch map u(well location. ❑Hollow ILud ❑Air ❑Bored ❑ � <br /> N <br /> � i i i Addition Name J�Rotary ❑Jetted ❑Power Auger <br /> -� -� � -� ti.DRILLING FLOID <br /> � � � Block Number �� <br /> W --i- -;- �- �- E 7. USE <br /> � �Domestic ❑Momtoring O Heat Nump <br /> _1_ _S_ _'_ '' T <br /> I ; � � f'm. Lot Number ❑Irrigation ❑Public ❑Industry <br /> � i ❑Test Well �O Municipal ❑Commercial <br /> '-�- �- - -r- I ❑Air Conditioning ❑ <br /> � � 1 milrr� 1 8.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address ❑glack HEIGH7':Above/Below <br /> . ❑Threaded.:. �. <br /> indicated above. Surface tt. <br /> ❑Galv. ❑Welded <br /> Drive Shce? Yes— No— <br /> JO� �T..s+.�� �Nlastic e� . <br /> tGi �y (� �} <br /> 4in.to y�T[ Weight IbsJtt. �n. td�'�t. <br /> 3. FORMATION LOG COLOR HARDNESS OF F'ROM TO in.to (t. Weight Ibsltt. —�n. to�t. <br /> FORMATION <br /> Y...1 1 ,�J in.to tt. Weigh[ IbsJft. —�n to�t. <br /> G.11 <br /> C� �� � �� 9.SCREEN Or�openhole <br /> � yT�J(� = from � tt.to. ft. <br /> Make 77c7Y�7 <br /> � i)�� �� �� TYPe " _ Diam.�3.n• l�'.�• <br /> �_. _N� '�+�� SIoV(iauze �v/�g/��O� � /� Length �FI 7'NGS: � <br /> l~�T�7�t�YC:l �'(,�f1� �L 6! Set 6etween �VV fl.and ��4J� (t. �}'w� � � <br /> C 10. STATIC WATEH LEVEL �9 <br /> ^Jl^��l ,�yjj� V7 77 66 ft.j�below ❑above Date Measured,�}���,al <br /> ���h • land surfacr� <br /> �d�} p I1. PUMPING LEVEL(below land surtacel <br /> C� � �� �iu•�,�{� • + ��O tt.after hrs.pumping �V g.p.m. <br /> �.7ii 1l��7 � (t.a(ter hrs.pumping g.p.m. <br /> SGsiwt �SCIT� C� � BrCfYl�l 1�.I� 11� 1SZ �Z. HEAU WELL COMPLETION <br /> �h �Pitless adapter manu(acturer }a�+�+� Model <br /> C��i'_�„Y� �� �Q� y�Q O Basement,oftset O At least 12"above ground <br /> —Vi. V 1 7 ❑plastic casmg protection <br /> �"i� 13. W ELL GROUTEDt �Yes ❑No ;,� <br /> Grav�1 189 205 <br /> �Neat Cement ❑Bentonite ❑ � <br /> Grout material [rom�to�ft.cu.yds. _ <br /> la. tiFAKF.Sf SOURCES OF POSSIBLE CON7'AMINATION <br /> (irl direction type i� <br /> Well dfsin(ected upm compleuon7 �Yes ❑No � <br />�` 15. PUMP x <br />� 14/91 ;� <br /> Date installed ��� O Not installid <br /> ": Manu(acturer's name �S���mt�� �� <br />�� Model number— —HP�:i��Volts� :�-� <br />�` �{�C3 (t. lapaci� 12 m. �Y <br /> Length of drop pipe 1y1.� y H�p� <br /> Material o(drop pipr y�r � �� <br /> Type: �Submersible ❑L.S.Turbine ❑Reciprocaling ' <br /> ❑Jet ❑Centrifugal �� <br />�,��� I6. ABANUONED WtiLIS <br />�;: <br />'!:i� Unused well on property? ['y Yes g[No <br /> � Use a second shee(,!J needed Sealed '] Permanent ❑ Temporary 0 Not sealed <br /> 17.REMARKS.ELEVATION,SOURCE OF DATA,etc. <br /> � I8. WATER WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best o(my <br /> knowledge and belief. <br /> Ste,vens �11 7rilling Co., Inc. 27194 <br /> /.irensee Business Name Lirense No. ;.:p <br /> Address <br /> 6240 . � Plain 1��d 5�359 � <br /> �� � � �f <br /> Signed -+�'""'� '"'--•--^' Uate r 3 1 � <br /> Authorized/2�•presenm(iue <br /> A'i1lK R1V�.Y'S .Date U5 1� �1 �„ <br /> Na me o(Dnller <br /> 47�364 5„'�M <br /> LOCAI_ �:OPY 7/7630M <br /> 7/78 30M <br /> HE-01205-03(Rev.9/88) 2ie2 tonn <br />