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<br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
<br /> CounryName WELL RECORD 5 20 4 6 4
<br /> t'f�x;Y.�..'L)1.I': Minnesota Statutes Chapter 1031
<br /> Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
<br /> C�rcr2c� 117 2� t:.� , t, ► h. �__,�_<._
<br /> . c
<br /> �. �. �.
<br /> Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
<br /> ��j�,� �''�Tk ��i,.�'�'� ���C)r1T•� I`�:. ❑ Cable Tool ❑ Driven ❑ Dug
<br /> ❑ Auger � Rotary ❑ Jetted
<br /> Show exact location of well in section grid with"X". �/J� Sk map of well location. ❑ '
<br /> � J j Showing property lines, �
<br /> N d roads and buildings. DRILLING FLUID
<br /> I � _i _i_ tit�'P.t�C_�'t.Z�:f?
<br /> --r- �- � i
<br /> i � i ,USE ❑ Heating/Cooling
<br /> _+_ _�_ �_ �_ C�`�Domestic ❑ Monitoring ❑ Industry/Commercial
<br /> yy i � I E ❑ Irrigation ❑ Public
<br /> _1_ _1_ __ __ T ❑ Test Well ❑ Dewatering O Remedial
<br /> 1 � '
<br /> f,m�. CASING Drive Shce? ❑ Yes ❑ No HOLE DIAM.
<br /> --�- ' i
<br /> � �- - -r- I �;Steel ❑ Threaded ❑ Welded
<br /> 1 ❑ Plastic ❑
<br /> �—1 milr ,�r
<br /> �✓�LL CASING DIAMETER WEIGHT ..
<br /> PROPERTY OWNER'S NAME �I't'�'; k t .i>t'+ �
<br /> in.to ft. Ibs./ft. : `�in.to���%�it.
<br /> � �?"f'�l i. �S
<br /> y,.,���..;;l.f�:>C:I l�.i,�,f�:' �'- in.to ft. Ibs./ft. in.to ff.
<br /> Mailing address if ditferent than property address indicated above. in.to ft. Ibs./ft. in.to ft.
<br /> -� - y - - SCREEN '� ;� �� � " OPEN HOLE
<br /> �i.,�.. ....:.I..��:`..'-J':' i i�:":r�: C�1..iaT:.�Tz—
<br /> , Make �.,�i��4j from R.to tt.
<br /> f'+;..,i �,..�,;i r ��:C�-.. . .._ Z ,- .,t ....:� .
<br /> - Type Diam.
<br /> SIoUGauze �- � Length a��
<br /> Set between �+�`�� ft,and ����� ft. FITTINGS:
<br /> STATIC,WATER LEVEL '���(l.._L�?
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO � ft. O;below ❑ above land surface Date measured
<br /> MATERIAL
<br /> '{ �;t .:.. � PUMPING LEVEL(below land surface)
<br /> �..1C.1y' . _. �
<br /> ft. aRer hrs.pumping g.p.m.
<br /> � 4,(.i�,�, y:✓f ��,.� WELL HEAD COMPLETION
<br /> � C`4.Pitless adapter manufacturer �^r^�r�"r��"<l+"..,,i. Model
<br /> ❑ Casing Protection C�,12 in.above grade
<br /> GROUTING INFORMATION
<br /> Well grouted? ❑ Yes 1� No
<br /> Grout Material ❑ Neat cement ❑ Bentonite
<br /> from to ft. ❑ yds. ❑ bags
<br /> from to ft. ❑ yds. ❑ bags
<br /> from to R. O yds. ❑ bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> feet direction type
<br /> Weil disinfected upon completion? <F7 Yes O No
<br /> PUMP .,,'j,_t.:
<br /> ❑ Not installed Date irlSiaU
<br /> i'�I��.-:
<br /> Manufacturers name
<br /> Model number HP Volts L"`��
<br /> Length of drop pipe ��'=�� ft. Capacity ��� g.p.m.
<br /> Pressure Tank Capacity �<< f-',�.�„i�l [�];�y tt
<br /> Type: 0}$ubmersible O L.S.Turbine ❑ Reciprocating ❑ Jet ❑
<br /> ABANDONED WELLS
<br /> Dces property have any not in use and not sealed well(s)? ❑ Yes 2J 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,ilneeded iA-`iV . .;...'�..X 3 r": v'vi .t(, 1!2�. 1 sta11'ul�� �.. , � .�..',i,,.. s::� :'y.
<br /> REMARKS,ELEVATION,SOUR�E OF DATA,etc. Licensee Business Name Lic.orReg.No.
<br /> 4
<br /> Aufhonzed Representative Signature Date
<br /> �„ �` y� ' " �- (�';
<br /> ��y/ �G G�",^��'��-.�-_� � �_-r%�...-_ ...
<br /> � �..� � ..
<br /> Name ol Dnller Date
<br /> �'.. . �•�:,ti�a:z,_.r 3—�:',. _ :.
<br /> LOCAL COPY 5 2 0�6 4 HE-01205-04(Rev.5/92)
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