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[ ATIO County Natnc WATER WELL RECORD 1L111%"1VESOTA UANUE WELL No-SEXRomm ` Minnesota Slatates 156A (11,08 for Water Sample 4 Township Name ownship Num Range Nu�W� No Fraction t WELL DEPTH Icompietcd, . j Uatrof CompletHm SIR luV1� 33 26 SB `sax 35 it 6o-92 Fiamerical�5q[reet Address and City of %*5 Location or Dityance m Rmd Intersecuon. 5 DRfLLJNG METHOD 450 CARY STR61ir OCable1 ul ❑ Reverse ❑ Driven O Dug how exact localton 1# well In wtaln gr eel wilh "X.' 5krtth map of well loeaewn. O Hollow i<ud ❑ Air ❑ Bored ❑ N W f milt �� Addition Name =I Rotary ❑ Jelled ❑ Power Auger 8. CASING 2. PROPERTY OWNER'S NAME Mailing Address if different than property address 6 DRILLING FLUID indicated above. namn Block Murntir E yr mi CITY OF Wali Kim 720 DODCX 7.IJSE XTT G omes[it onuormg Cl Heat Pump ❑ Irrigation ❑ Public ❑ Industry WOUr 11 Galy- 9 Welded Drive Shoe? Yes I No____ f milt �� Addition Name =I Rotary ❑ Jelled ❑ Power Auger 8. CASING 2. PROPERTY OWNER'S NAME Mailing Address if different than property address 6 DRILLING FLUID indicated above. &Mtonite Block Murntir E yr mi CITY OF Wali Kim 720 DODCX 7.IJSE XTT G omes[it onuormg Cl Heat Pump ❑ Irrigation ❑ Public ❑ Industry Loc Number 11 Galy- 9 Welded Drive Shoe? Yes I No____ 1�1•[ KXM, ❑ Teat Well ❑ Municipal ❑ Commercial 1 O Plastic O 4 in to 170 ft. Weight 10.79 An. 3. FORMATION LOG ❑ Air Conditioning O f milt �� 8. CASING 2. PROPERTY OWNER'S NAME Mailing Address if different than property address �� HOLE DIAM. HEIGHTIBctow indicated above. F lack ❑ Threaded Surface It. CITY OF Wali Kim 720 DODCX dY=W NW 11 Galy- 9 Welded Drive Shoe? Yes I No____ 1�1•[ KXM, 10 55330 O Plastic O 4 in to 170 ft. Weight 10.79 An. 3. FORMATION LOG COLOR HARDNESS OF FROM TO Ibsen- I.M. FORMAT[ON to to fl. Weight lbs./ft. n. to !in TOP SOIL In. to ft. Weight IbsJ[t. to ft. swr 0 3 9 SCREEN 355 Il. to. ft. SAND BROW SOFT 3 15 TY pe Dlam. GuY NED 15 35 Slot/Gauze Length FITTINGS: Set between fl. and ft. STXCU MAY =zz SOFT 35 65 10- STATIC WATER LEVEL it ❑ below above Date Measured 3¢27197 land surface MM. SAM an 65 83 11 PUMPING LEVEL (below land surface) [t after hrs. pumping g,p•m ©AT OR SHUX OST WftY�o 83 90 ft after hrhrs.pumping gpLm. 12. HEAD WELL COMPLETION LBULTWU CRR �Agi Mwit#ia �J iA JO 92 ❑ Pitless adapter manufacl r Model 'C Basemen[,offset � At 1ra�l 12" above ground Cl Plastic casing protection ("Y Ca 95" Gl= M 92 120 13. WELL GROUTED? Al(Yes ❑ NoSANDSTMW s LT+ cam r Wheat Cement C3Bentonite ❑ - 45 SHAM a�u�saala T" = 120 135 Grout material A111111st from 0 to L I ft. cu. yds SANOSTIM SHAM LT. ME= IMD 135 155 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION cv-* a SiANDSTOW SKAU WHITE/ AN SM 155 240 feet direction LYPe SAMMMM $11�a PI]ilC � }% 240 270 Well disinfected upon completion? ❑ Yes ❑ No SANDSTTIM 15 PUMP W / Date installed-•'�� MS/4llt �t Phil[ R"D 270 ' « _. installed Manufacturer's name Model number HP Volts SANDSTORK PYi� HA1tD 300 355 Length n(drop wpr ft CapatilY &0.m• Material of drop pipe Type: Cl Submersible ❑ L.S. Turbine ❑ Reciprocating ❑ Jet ❑ Centrifugal Cl 16. ABANDONED WELLS Unused well on property? ❑ Yes J*No Use teen ltd slleel, if needed REMARKS, ELEVATION, 500RCE OF DATA, etc. Sealed ❑ Permanent ❑ Temporary ❑ Not sealed N� /tea /O, 18. WATER WELL CONTRACTOR CERTIFICATION lbrk Performed Under Direction of �- '; �1 This well was drilled under my furisdiction and this report is bile to the best of my ftier Stewart ` Aissociattei eek %J2r knowledge and belief Mr. Kirk Roessler (6=2)774-6021Lirensrr rr71015 stneYs nays ��- f.uenuNo, -- y Address "`"1 -Am 5 330 ' •- _� �, ..: t • :a Signed Dale �.ry' Aulhtrtrerl Represen[atlae • - ' --92 3-27-9 Date3-27 DENT- OF HEALTH COPY 4 Name �f rh(ftcr 7/730M 71760 30M vC n•-ne n�r_- nen... 7/7R VIIIA