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� STATh:OF�MINNI�:S()TA DFYAMTMF:NTOI�MULTH <br /> I. L()(ATI()N()I-W4�LL FI/NNf:50TA UNfQUF WEl.L NO. <br /> � � ,�: -� .� � <br />.� CnumyNume �� � WATER WEIL RECORD ��,w,«.samor �� „ �,� „� � .p <br />�"y+. �� � MinnriotoSlaMfIlISM1A.III�.lIN . <br />� T��wnxhip Name Tnwnship Numher Nan`e Numher y�cti�n N�. I�r�a�lli�n J. YROYk:RTV OWNk:RS NAM! ;� <br /> ' Oro� 1ITt�, s� �3�' W 5 s�r '`� y awa' �:�l��ia Pe+tersorxl� ��Lc,s <br /> c,�' 1)islan�r anJ I)vecl�un(rum R�uJ In�<nec�inns��r Slrc�i AJJress and C�IY of Wsll Lnc�liun A�d!�. q7g �g�� .�,.Rd� ) i', <br /> �' �or�� �, � _ 55356 ; <br /> � Snnw ea�at liica�ion i�f well in rec�l��n griJ wilh"X." Ske�cn map of well Ir�c�tiun. a.WELL DEPTH(completed) D�te of Completion <br /> M ! <br /> �.�� � ���,�;,,��,m� a_6„-�� ; <br /> � -� - - ,-- -�- - - «. ; <br /> � s. ; <br /> ,>s: � , � ipc.nir�ooi a❑Ke�rrse �On.�.�� �o0u�� <br />" �. N -' - -`- -�-I� - E ylock Num�er Z❑HnllnwruJ SOAir BOBnrod I I❑ <br />��_-.V� i _ '_ '` � <br /> - - 4.n. �C�,�i�rr e❑ieure aOv��we�n�e�r <br /> ����- ' � ' � � Lot Numher 6. USE � <br /> .� '_i_ ' _''' _ "_'__ � <br /> I�nmestic 4�YuAlic Su00�Y '1�Induslry <br /> ?k i i r <br />:e� J <br /> F-1�1l.tt� 3❑IrriH+ti��n S❑Municlpal <br /> B�C�mmercial <br /> H�IlI/Nf:SS OF <br /> I. FONMATIONLO(: �('OLON F()HMATIUN fKOM TO lOTect Welt 6OAir(1�ndilinnin� 9❑ <br /> 6t ,p� =q 7.CASING HEIGHT: Above�Below NOLE UTAM <br /> �r�� �Vi�w/i.� V � I�Black. 4❑ThreadeU � <br /> �2 3�(:alv. 5❑Welded Surfece /t. <br /> " $� �� � �� ,7[�105tFC 6❑sO�����Drive Shoe? Yes_ No�� � <br /> .�_in.Io 1,�]$ !f. Weighl �� '�� Ib�./ft. �in.ro� , <br /> CI.��-j§Z�Tttl �TZ.�'�Tta �S '�� _� <br /> in.lo fl. Wei`ht Ihs./f!. n.to_fl. <br /> in.to R. WeiRht Ibs./ft. _in.to_fl. ' <br /> gravel brcr�a 9t� li�S B. SCREEN �4 �� .op�� o�� <br /> Make from (1.�o ft. <br /> ��ale—grevle rod—i�►rw 1�s5 13t� TY,� P�G o,.. 4" <br /> Sbt/Gauu �Fd Len t� �py �{.yy-+� ' <br /> y���'��, rQ(j��}� ��y ,;.�� Setbetween � ft.anA �ft. ��� � T�� I� `! <br /> �' t�r�l. ClC v'd1V�: <br /> ��.a�a ��. <br /> 9. STATIC WATtR LEVF:L � <br /> �� f��helnw ❑ahnve Dat<Measured ���� � <br /> - land surface ' <br /> 10.PUMYINGLEVEL@elowlandsurface) t('�()� . <br /> iVW i� <br /> e�.aner n...o�mo�os e.o.m. <br /> ft.afler hrs.pumpin6 6�V�m� <br /> 11.WELLHEADCOMYLF;TION <br /> ��Pitlesx etlepter,manutacturer model �� <br /> ]�Baeemenl of(sel 70 At lexst 12"above grede <br /> 12.WELL GROUTED? � <br /> L�Ye� ❑No <br /> 1�`7<al('emenl 7�Benl��nite J❑ � <br /> Grout ma[er�ai from to (t..Cu.YAs. � <br /> 13.NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> L�<«, a,.e��,o� �Yo� <br /> Well disinfttfed upon complelion^. Ves� Na❑ . <br /> 14. PUMP <br /> Date installed ❑Not insta11e0 � <br /> Manufac�ureiS Name ���Q�` ' <br /> Model Numbcr HY_�Volts � <br /> Length of droD P�D< � ft.capacilY ��e.p.m. . <br /> � Material o(droD D�De ��aC��lts �� <br /> TyDe: I�Suhmi•rsihle ��L.S.Tutbine 5❑Iteclpnrtaling �' <br /> 101el <�C'rnlrifu6�1 60 , <br /> Use a semnd Sheet,if needed 16.WATER WELL CONTRACTOR'S CERTIFICATION <br /> 15.REMARKS.ELEVA170N,SOURCE OF DATA,etc. This well was drilled under my jurisAic�ion and t�is reDort u Irue lo ' <br /> the Desl of my knowledge and beliel. � <br /> �. �SCBY@A!d C��3.Z t:O ��I�li <br /> ' C..- �� ZO t�- •-� -- .� Liceruee Bu+lnen Name Lieenx No. ' <br /> ; �` E� f-� a ; tJ��;L�' i�`. . ; <br /> �_r <br /> :.i F _ �� ! „�� 624� 2 � �i 1 ` `� S9 .; <br /> _ .�`.__. - -- <br /> ', � ' ---� _._ s � <br /> MAR � 8 rgg�; ° ' r <br /> 1� � 5�6 d � - . .:✓� . � ..�� .. Date� 1 <br /> Au1ho�xed Repr enutive � <br /> � <br /> �r � � Cid.�.'li ai��n�� D�te �'^��=" . <br /> \ � Name o!Driller ,� <br /> ..,.... .,� - ,. ,. <br /> 5/7d 30M <br /> � � I _'_- r, 7/76 30M <br /> _ � �/7B 30M � <br /> '' M <br />