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CT►K ,tF ul\\FCAT► DFPAVTUF\T OF IIFAI.'I'H <br />C1.0CATION OF WE WATER WELL RECORD AIlVVESOTA UNIQUE HELL SO. <br />argty Name <br />�. gar if at" Sample 442431 <br />Alina is 5141.1e; 156A.01 ..ON <br />ownsh-p Plamet[Township <br />Numbtt <br />117t: a <br />Ran'gey�N.'umber Srctim No. <br />23'►�1 a Ia <br />Fraction,,T,+ .'YET <br />JU 40 'A,7il 'A <br />J. WELL DEPTH Imm�te=t <br />11 <br />DatS otC�Q� <br />ML�� <br />W <br />It. <br />D,auesce and Direct= frorn Road Intersimlion or Street Address and Lily of Well lecatiun <br />5. DRILLING METHOD <br />10 Cable tool 40 Reverse 70 Driven 1ti3 this <br />20 Hollow rod 50 Air so Hored Ito— <br />Shm exact localm ofwell to section grid with "%" - Sketch map d .,It taatnn. <br />M <br />y�[ <br />I <br />Addition Nae <br />Addition <br />Notary 613ktted 90 Power Auger <br />6. DRILLING <br />iM 6 kxk umber <br />7. UXSE <br />�_ i_ s_ <br />10 Domestic {O Monitoring !r]Heat Pump <br />1 Lot Number <br />201rrisation so Public 901ndustry <br />6'mi <br />30 Test Well 60 Municipal t00 Commercial <br />—�— �— —r I <br />1 <br />70 Air Conditioning t10 <br />. 1y <br />a.p--a <br />H. CASING <br />HEIGHT: Above/Belowi„w <br />10 buck 40 Threaded <br />Surface—Kit. <br />20 Gaty. <br />HOLE pAyA. <br />2. PROPERTY OWNERS NAME �.,� ����pp / <br />1" � / L 0� <br />Address �5 � .St. <br />50 Welded <br />Drive Shoe? Yes_ No_ <br />' <br />nay, 1►�+1,55323 <br />214 1.99 <br />8 222 <br />_Crystal <br />_ <br />m. to it. Weight lWit. <br />in. to U. Weight Ibslft. <br />in. to It. Wright lbt.fl. <br />in. to—Jt. <br />_Jas to—fl. <br />In. Io ft. <br />3. FORMATION LOG <br />COLOR <br />HARDNESS O) <br />FORMATIO. <br />FROM <br />TO <br />Tp__�* <br />jQ�j <br />Blacko k <br />V <br />I <br />9. SCREENfohnsm Or'openhok <br />corm fl. its ft. <br />Make s <br />Clay <br />Tan <br />I <br />S <br />Type3 n Dia._ <br />SIdlGaurr LrMh—VVF'ITT�awf�GS: <br />MAY <br />YC IW <br />3 <br />♦�• 7' <br />Set brtween It. and f1.3 X 4 x — packer <br />t <br />C;3ay <br />ss��� <br />Bim <br />Utz <br />I9 <br />�ft�..• <br />205 <br />10, S6%,3C WATER LI*L 6-28-88 <br />i4 <br />WI <br />I,.Ohelow Oabme Date Measured <br />lard surface <br />�'` <br />a��19 dstme <br />i�n'le <br />205 <br />�S�rf <br />222 <br />11. PUMPING LEVEL 1Dcbw land surface) 1 n» <br />�W <br />ft. after hes. pumping s.D.m• <br />it, after hes. pumping Spin, <br />{� HEAD WELL COMPLETION <br />117 ihliess adapter. manufacturer model <br />20 Liasement offset 30 At Last 12" above ground <br />40 Pb%tic casing I'rolechr <br />3. WELL GROUTED? <br />[I Y- O No <br />R7 Not Cement 20 Bentonite 30 ID 30 <br />Grout material from to It. cu. )ds <br />IJ. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br />feet d.mi.2 type <br />Well disinfected upon completion? O Yrs O No <br />Is. PUMP 6-30-08 <br />Date installed O Not installed <br />Manufaciurer i name <br />liz <br />hladrl number IIP Ydt- <br />i0o 12 <br />Length of drop Pie PW It. opacity s.p.m. <br />Material of drop pile <br />Type 1: 10 Suhmrtsible 313 LS. Turbine !U Recilaoating <br />_ <br />20 Jet 10 Centrifugal 60 <br />16. EXISTING WELLS x <br />Unused well - proper&? IIYe, O No <br />Uua <br />sAerl, if rvnled <br />Abandoned OX Permanent O Temporary O Not seakd <br />,etc. <br />17. REMARKS, ELEVATION, SOURCE OF DATA, etc. <br />18. WATER WELL CONTRACTORS CERTIFICATION <br />This well oras drilled under my jurisdiction and this report is true to the hest of my <br />krrowl,dge and belief. <br />Saf.im WeU }ril� 27174 <br />6M'1 ''32 W bU%" Platnsse ASS353 <br />Add <br />j <br />Srgned Date <br />Authoeired Rrprrsmiativr <br />i <br />wi`i = Date <br />LOCAL COPY <br />4 a 2 4 31 <br />Name of Driller <br />Si71J0M <br />71 3 <br />77700M <br />LIE01205M (Rev. lOiiiS) 2192 101a <br />