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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL RECORD 522181 <br /> f-//i I/7 , i , ,,,..-7 Minnesota Statutes Chapter 1031 <br /> Township Name Township No. • Rang No7 Section No. Fraction WELL DEPTH(completed) Date Work Completed 9 <br /> /�.)N ) 1 1 7 i J7 M/ I1/ 5(1:- -� tf ft. <br /> ( :f <br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD <br /> t 1 3 / (...,,, /.4,,,54- 7"/ ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger fq Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. 0 <br /> Showing property lines, <br /> N roads and buildings. DRILLING FLUID <br /> I ,__i_ l..r./ , • i <br /> i i, USE ❑ Heating/Cooling <br /> E L Domestic 0 Monitoring <br /> ), 17Industry/Commercial <br /> w i i I , E 0 Irrigation 0 Public ❑ Remedial <br /> 1_ 1 0 Test Well 0 Dewatering ❑ <br /> CASING Drive Shoe? 0 Yes ❑ No HOLE DIAM. <br /> --:- --- ---,-- 1 '''/A ❑ Steel ❑Threaded 0 Welded <br /> • <br /> I--1 milr Plastic ❑ <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME `'/ in.to ?V i ft. 1 . r r_ lbs./ft. d" in.to ( ft. <br /> j-0 1'+✓1 C G//f/ 4-• y in.to ft. lbsift. in.to -f/MC <br /> Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make •If. • from ft.to ft. <br /> Type "L Diam. - <br /> Slot/Gauze _e, 5"/..,4-• Length ' <br /> Set between ._ l ft.and `I G• ft. FITTINGS: - ! <br /> STATIC WATER LEVEL <br /> GEOLOGICAL MATERIALS COLOR H IRDNE ISLSS OF FROM TO 10)6 ft.A below 0 above land surface Date measured <br /> PUMPING LEVELf (below land surface) <br /> • t: ft. after hrs.pumping /rt.,' <br /> -_ / - 1 �. I I� P P 9g.p.m. <br /> WELL HEAD COMPLETION <br /> .c 1 ,/ (/' -/.,J O?I .5 4v Pitless adapter manufacturer (.ft) %.„/e/ Model <br /> 0 Casing Protection 0 12 in.above grade <br /> '. t '//(; •" 1 .i a f, - � GROUTING INFORMATION <br /> Well grouted? ill Yes 0 No <br /> 1, -r <br /> t' I ,//Cr CLI J)y Grout Material 52 Neat cement ❑ Bentonite <br /> from .C' to (-- ft. 0 yds. ❑ bags <br /> from to ft. 0 yds. ❑ bags <br /> j- from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> feet y- h direction -' "' " type <br /> Well disinfected upon completion? X Yes 0 No <br /> PUMP <br /> ❑ Not installed Date installed 2 ,I( / <br /> Manufacturer's name I- t r..-c/ <br /> Model number HP / Volts 9 1 <br /> Length of drop pipe I ',/ ft. Capacity /•-2 g.p.m. <br /> Pressure Tank Capacity <br /> Type: yz Submersible 0 L.S.Turbine ❑ Reciprocating ❑Jet 0 <br /> ABANDONED WELLS <br /> Does property have any not In use and not sealed well(s)? 0 Yes Ef..No <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 /> Use a second sheet,if needed ,6?, r. (:). -. % 'l 0/,',/ . , 1 ] 7 c <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Lice1nseeBusiness Name Lic.or Reg.No. <br /> ,1. t / ,.-", r,. 1 r� , ( _ X1,4.__, U i, j -.9-ci 2 <br /> Authorized Representative Signature Date <br /> Y9 <br /> 1-f ) 1 A)) i hi d V 2 '1 7 i-t i. fk'". - <br /> • <br /> Name of Driller Date <br /> LOCAL COPY 522181 HE-01205-04(Rev.5/92) <br />