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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CounryNa�n1 Hennepin WELL RECORD 5 613 8 8 Minnesota Statutes Chapter f031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed t1 x-��no 1 1% �'� f;r;, 1 �:-t�U i t�: � -;:. r n i � _,- c'�:. ��. ��. ��. Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD [;7�`•l.� Cc:�un�try��1C�� D�. �. �(Ji1� I.r�:1wE±� ❑ CableTool ❑ Driven ❑ Dug ❑ Auger O Rotary ❑ Jetted Show exact location of well in section grid with"X". M�. J�jSk�tch map of well location. ❑ J�6howing property lines, N � roads and buildings. DRIL�ING FLUID . � � � �'vj Ird��. . "r"-1_ _1 _1_ � i � i � � i �� ,USE ❑ Heating/Cooling ._�_ ___ �_ �_ �Domestic ❑ Monitoring �- W � � � E ❑ Irrigation ❑ Public ❑ Industry/Commercial ' ' ❑ Test Well ❑ Dewatering � Remedial -1- -1- -- =- T .� o ' � ' f,mr. � . , � CASING Drive Shce? � Yes ❑ No HOLE DIAM. '-�- �' ; -r- I ,a ❑ Steel ❑ Threaded ❑ Welded � ' 1 ,� � � I�.Plastic ❑ �'-1 m�lr� .,..lJ 1`�{�-�i �,J � Ae+ CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME �> ��F; �DRa�� / ��/ � in.to tt. Ibs./h. iR to "f�. i 021Y �,a_C;E333 �.UI!'t�ei Xl� in.to R. Ibs./ft. -Z-iR.��' R. � Mailing address if different than property address indicated above. in.to R. Ibs./ft. in.to_fl. SCREEN OPEN HOLE z�:� 1 +;r; IsEr.k�:hire Larae --i�i-�i�i-btxr�on Make from ft.to tt. ��1�7ii1C�l?t=i7� �Il. C��;y l:� TYPe .�t_":ZIl e5.�a ..�i�2E'�. Diam. ^no Slot/Gauze 1�� 'U Length V Set belween �6 Ej ft.and__U_Lft. FITTINGS: � 1 � f:fs STATIC WATER LEVEL GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO 1t t` c: ;r: MATERIAL � h. CJ}�elow ❑ above land surface Date measured � ,� , PUMPW�'a I.�VEL(below land surface) i - . c � J.; ' � l.l.%rt y Y e I�.o�} : C' !i ft. after � hrs.pumping -'� g.p.m. WELL HEAD COMPLETION �l�ty �.yrE'�; ;,,� �U � � �� C'I�Pitlessadaptermanufacturer ��1'�'e'"��'�`'�'�"'r'Model ❑ Casing Protection C�12 in.above grade Gra�ty�.� L1ci V Brc��yr� �J j t;[. ` �{y` GROUTING INFORMATION Well grouted? L�1 Yes ❑ No Grout Matenal ❑ Neat cement �SBentonite S8 �`..ic:llfi `7�ci Il :� � _;_ � ��'i�- � from �% to �'t�ft. r• ❑ yds C�''bags from to tt. ❑ yds. O bags �.�.c'.`T �+r{76YI1 �.r'> � � � ��. p from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION � / diredion c' �. . ` a r`� ? feet �- .�a tt r `I�.n � 1�(' i i. .�,�- , � [-��'"r� �.L__�ryae Well disintected upon completion? �0��+1'es ❑ No PUMP ❑ Not installed Date installed � `��! � �-��-� Manufacturer's name,t �. �� C�S ,,.� �f�_: -��:T�- Model number HP Vol�sC� b Lenqth of drop pipe � ft. Capacity � g.p.m. Pressure Tank Capacity #�L J�: �S-^t.1:�C,.1 Type:y47 Submersible ❑ L.S.Turbine ❑ Reciprxating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes C3kNo WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. t`�..t�Pv Sri'��D(=!Li"', tivEI,L DRII�IaING t;:l.�. , I JC;. ., Use a second sheet,il needed REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name / Lic.or Reg.No. �;� .;'� �,:: 11_s; .c� � ��. _ ,. '" � uthonzed Representahve S� af .--�"�� Dafe `�� ` � ��5b �'r�r� Lei.b�� i L-5-95 Name ol Driller Date LOCAL COPY 5 613 8 8 HE-01205-04(Rev.5/92)