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STATF�.()4 MINNF:S()TA Ok'.YARiMlNTOI�NtALiH <br /> I. Lnl'AlI()N()I�H'h:LL F/lNNFSOTA UNIQUE WE/.L NO. ,� _., � � <br /> � � <br /> c„���r��,p�,.y•��� p W A T E R W E L L fl E C O R D ��,war�.samo�e � �j- � �A r .m� �� <br /> '�VF4ii�G4��X4 Minnriora Srenlrrf/SM1A.111�.11x �� �� <br /> I'��wnshi�Name Towns�ip Numher Nan�e N�mher y�c�inn Nn. 1 r��clii�n J. YROYF:RTV OWNF:RS NAMF: . ( , <br /> N E .. / 4. <br /> �,:+Y'filKJ ��.�1 �` S` .�.3.� �'H` � iit�i r9.� :.rfd i:.� '. � <br /> I)islani�and 1>kecli��n frum H�uJ In�ersec�i��ns�ir SIrce1 A�Jress anJ C'ily of Well Loc�liun AddreTf,�� � <br /> f <br /> ';.:Z'�Ef�"1eV :. ��CB � u7.'c?� <br /> Snow ec�c�I�rc�tion of well ln ttcliun Bri�wilh"%." Skelth map of well l�xatiun. 0.WF;LL DEPTH(completed) D�le of Completion <br /> N ,-�,-, <br /> ' �r ' AJJilii�n Name . �:'�.� <br /> _ L _ _ � '_ti. _ �� ft. ��-i,r.� w.:.� . <br /> � � � s iOc.nir�����i aOH�.e� o❑rn�.e� �o❑o�e <br /> M - • - -�- -+-I- , - E u,,Kk n�m�n <br /> y z❑H,m��w,��u s❑n�� eOa�,ed n❑ <br /> —�� '' —� i}�11.. J�H��t+rY 6❑Ieited 9�Yower AuQer <br /> I � ' � � Lo�Num�er b. USE <br /> "i_ ' __' _' ___,_' <br /> iQ�lrn,mr�n� a❑v�nu�soovir ��i�a�:vr <br /> $ <br /> �-1 nII:U 2❑Irrigulinn S�Municipai B❑Cmmmereial <br /> l. kONMATIONLO(i ('OIOH H�HItNt:SSOF F�µOM TO <br /> IONMATIUN JOText Well 6OAir('��ndifiunin� 9� <br /> ]�.�C/ASING HEIGHT:AAove/Below HOLE DIAM <br /> .[���Q'� u�:;E.� �y�x� y�j�'� 4! �� If.JMack t��readeJ <br /> •c V <br /> 2�(;alv. 5❑Welded Sur(ace ft. <br /> ���� `��`�.� j�p ��� ,�� �� J�PI25tIC 60 Drive Shx! Ye�_ No_ <br /> _"',r 4 <br /> �n.to � ft. Weighl Ibf./h. —In.lo_f�. <br /> -'?,�.II� � C�?7.� �3�1a1T1 ;:3Cl�. �1� �� ��.�� «. we�em ins.�r�. —�n.�o_tc. <br /> ��.�o n. w��■n� i�.m. _i�.�o_rc. <br /> �y Q,� � 8. SCRk:lN��n� ropen ole <br /> til%-F�� U����l r.'.Q�� W �' <br /> Make �f �rom h.to ft. <br /> EiLs3.�.T1�.8'�i$ 8'��f3�. �: <br /> Type Dia. <br /> � � • <br /> Slot JGau ze Length <br /> F'ITTINGS: <br /> Setbefween h.and (�. <br /> n.a�e n. ' <br /> t'�.a 'v'�t.'fTYi".a i J!� <br /> 9. STATIC WATk;R LEVE:L �„ <br /> Y.�j� �jI� 9 <br /> ft.�helnw ❑ahove DaleMnsured •r�/ <br /> — --- — land Surface <br /> 10. PUMNINGLlVEL(belowlanAsurface) <br /> fi.afier hn.pumpi^6 � 6�F�m• <br /> h.aher hrs.pumping g.p.m. <br /> 11.Wk;LLHEAUCOMPLF:TION <br /> ��Pitless edap[er.menufecturer moAel <br /> 2�eas� em orrsn �O/+�leut 12"above gretle <br /> — 12.WELL6ROUTED? <br /> I.J�fe� ❑No <br /> — — I❑Neul('emen[ $U�enli�nile 30 <br /> Grout meter�nl from ft..Cu.Yds. <br /> _ l3.NEAREST SOURCE6 OF POSSIHLE CONTAMINATION <br /> � � � feet direclion type <br /> r � � r � ��--,.� �( <br /> � � � � � Welldisinfecfeduponcomplel�on". Ves'L'7 Nii❑ <br /> 5. <br /> 10. PUMP <br /> i <br /> ! <br /> �� !3R`'-�� Dale instilled ❑No�inslalled <br /> ±��� ManutacturetYName ;:ytm�����` <br /> 4�Z. <br /> � ModelNum�er . HP�Volls <br /> t„ <br /> Lengih of dro0 Cipe (t.capaci�Y B.p.m. <br /> � �� <br /> Material of,ydrop p�pe <br /> Tyve: IL�TSunmersinle ��L.S.Turbine s�keclpn�catinQ <br /> 2�)rl <QC'enlrifugdl 6� <br /> Use a second sheet,it needed �6.WATEH WELL CONTRACTOR'S CERTIFICATION <br /> 15.REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> This well was drilled unEer my jurisdiclion�nO t�it report is Irue to <br /> �he best o(my knowledge and beliel. <br /> i.:s?tl'�3�1!'�.' ���.� ti4• �()�e:� -- � <br /> Lieeruee Businai Name Llcenn No. <br /> _ „�,n., :�Qx 159. Yictcrirq►. s�n 553#�a <br /> .. �� Si6ned �����i6�/ ��.G/�...��Dafe __— <br /> Auth�ed Repruentative <br /> .n2111F;�i ,.E�iP�'�.E?� n.« � � �! <br /> 5/ Name of Driller <br /> �.,..✓'�,5-c� �<�J�.1 � y '�°�� 5/7430M <br /> , R�� 7/76 30M <br /> .. .».e,. 7/78 30M <br /> HE-01205-Ot 2/82 10M <br />