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MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> � WELL RECORD 5 4 8 4�4 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Township No. - Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> Gr.r�no 71� �� �:� _ �:`:t,��.. ,. 1tif��° � 11-4-:�<;. <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> (j�=j ����-jyM ��� �-�� ��� ��c�c'";(;� ��p,, ❑ CableTool ❑ Driven ❑ Dug <br /> � �� �{� ❑ Auger Q�Aotary ❑ Jetted <br />� Show exact location of well in section grid with"X". �; Sket h j,nap of well location. ❑ <br /> n r" ����'�" howing property lines, <br /> N �,.=�� roads and buildings. DRILIING FLUID . <br /> i � � � i � :1: �:_t'_ <br /> __r__.y_ _i _1_ <br /> i � <br /> � � � i ,USE ❑ Heating/Cooling <br /> __a_ _�_ �_ �_ L`'I Domestic ❑ Monitoring ❑ Industry/Commercial <br /> W � � � � E ❑ Irrigalion ❑ Public <br /> ' T ❑ Test Well ❑ Dewatering � Remedial <br /> _1_ _1� __ 1' I ❑ <br /> � � i <br /> : � � i <br /> f•mi. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. <br /> i '—;' �' — —�' I � `_ ❑ Steel ❑ Threaded ❑ Welded <br /> 1 J( w:. �' �Plastic ❑ <br /> � 1 mil�—� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �' in.ro �1-�ft� Ibs./ft. � ��,� `+{�. <br /> .�s.t2 �etirrIl <br /> in.to fl. Ibs./ft. �j ��Yp �E_�. <br /> Mailing address if ditterent than property address indicated above. in.to tt. Ibs./fl. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make ���1 from ft.ro ft. <br /> TYPe �:3�i �.(�S ��.�E'�. Diam. <br /> SbVGauze �f` Length '' � <br /> Set between '��� ft.and '��� ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO 3 1 1^"t�'—i��: <br /> MATERIAL �, h�� below O above land surface Date measured <br /> Cry ..� �r;.: PUMPING LEVEL(below land surface) _ <br /> .lt't�' ... ti Jt� <br /> tt. after hrs.pumping g.p.m. <br /> � WELL HEAD COMPLETION <br /> *S- r`.' �4b �L11'..£.'4».�c:�'L-'.i. <br /> �itless adapter manufacturer Model <br /> ❑ Casing Protection �I 12 in.above grade <br /> GROUTING INFORMATION <br /> Well grouted? �„'I Yes ❑ No <br /> Grout Material ❑ Neat cement �entoni� <br /> from �� to_ —� R. f ❑ yds. C3`bags <br /> from <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> -. : � . '_.. "� ::i... ,, i. <br /> : � s�-, feet .�f�:r .. � direction - .. x � tyPe <br /> Well disinfected upon completion? �Yes ❑ No <br /> PUMP <br /> ❑ Not installed Date installed �F"�G:.L.�'J'Y <br /> Manufacturer's name ������-'� <br /> Model number ��S�=�7��' sL�k{��')t� HP�._ Volts 4��� <br /> Length of drop pipe ')��i ft. Capacity i}� g.p.m. <br /> Pressure Tank Capacity � <br /> Type: C�;Submersible ❑ L.S.Tu�bine ❑ Reciprocating � Jet ❑ � <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes QtNo <br /> � WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> �,.� Jr.���.%�.✓.'� Vll��,�.rs �... <br /> Use a second sheet,i�needed ��.a��a �.� T.�VI.. G.! f l L, <br /> REMARKS,ELEVATION,SOURCE OF DATA,eta Licensee Business Name Lic.orReg.No. <br /> j 1"i--�--9�; <br /> �.���"►�' ��!� <br /> A P R 4 1995 ���Authorized Representahve Signature Date <br /> ts.�°. �'.l�"jc.`!1��� � �—��.-1''-- <br /> Name ol Driller Date <br /> LOCAL COPY 5 4 8 4 7 4 HE-01205-04(Rev.5/92) <br />