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- MiNNESOTA DEPAIiTMENT OF HEALTH �mn��nt�v�+cii�na�r,ring � .�t i •. • �
<br /> WELL OR BORING LOCATION WELL AND BORING SEA�.IN� RECORD Mlnnpe d a�UrU�u�W�11 No. �����` � _`�`"
<br /> _ ----r---�-�
<br /> County Nam� r
<br /> �, ��i �ov.4v+ Mir,ne�ot��tarui��,Chayter io3� Ur W�eri��Nu,
<br /> Y (I.cavc t?!nR d h51 wMnn) ._ .. ..
<br /> . . _ . .. . _... .. . .. .. _ .... ........._ ... ._ .._._._ . ___ c..._ . ._.._
<br /> �
<br /> 7qy�nship N m� T ship Ne. Ranqe Nb, S€clkrn No. P�raciksn(�m.-�Ig.) hat��eaiea ds��W�i!ar�3�ring Cnn�Irunletl
<br /> � . _. I 3�O Z� s- ��'s�'' ��V �t - 2�C - 2a_ _ 'i-29 y 2 0
<br /> GPS LOCATIdN� decimel tlegr��s pn lour 6�cimal pigc�e) , ,
<br /> bGryth 4ii 7int6 bf 5tati�,g_�---1t. briginsi Depth____.�tl __---H,
<br /> Lelfludd�_ �._ Lon�ilUde----------. _ _ _ .. _
<br /> - _ ,�„�_
<br /> QtJIREa(8) BTATIC WATEFi LEV�L
<br /> _ .. _ . ,.
<br /> Numar�cel Str�e1 Acitirg�9 or�Ire Numbcr and City o1 Well ur 8nring LuCetlon �ingle pqWter (- Mulfiaqui�er L�
<br /> u
<br /> -
<br /> WELL/k10RIN6 _'M�asurcd D€�te Mv��ured--- ---___ :. :�snm�4e�
<br /> IJd J,Nt ► • � � .�'�i� + w'S `�Wgt��=5u�sply Well -vi�nv,W�II��,S"� •
<br /> 5how�xar,l ioc�tinn�1 weA oi twrinq Sk�tch map nl well nr boring ;-T�m�:�nv.Weli ��th�sr��A _ .��_f1. �b91ow ;above land gurl�s¢
<br /> in soelion qrid wilh"X" lo�tion,ghowin�pm�erly
<br /> linns,road�,air buikfings, _-- - _ .. _. . __._ . - -- - - ---.ur
<br /> ty . CASINOYYPE(S)
<br /> ..�.... .... ._.i._ ��� �
<br /> . � ,
<br /> ;5t�el I_�PI&91iC --''�iilb �CRho�.----��}---------------,-------__--
<br /> , , , � .. _ - - - -
<br /> � � , , _.� -- - - _�, -
<br /> __ _ ..
<br /> � _ - _._. ... -- -_
<br /> - •�!-- �' WEL6H�AD COMPLE7YON
<br /> ve ,'... ,_ ;.. , �� � ,_
<br /> ..{....•�--.•.}......}.. 4utsid�: �_!f�itles�Adep�edUnit ;._1 At f�r�de Jnslda: � ;t3aserrtent�(tset
<br /> 'f PAne� � � I;W�lI Ril � �url8d =,'W�11 F1�u@a
<br /> 1 ; t 1 I � � - W�I!pi1
<br /> . . �..,_.. ..r.. .........:.. . �--�
<br /> L �"Jlgs,� �(7tFier-----�--�-�-----------_- - ^.
<br /> � � Z ��r . !_J�turi�t!
<br /> }-�•-�--t Mac�-�-1 � �_i dltser _--
<br /> � .,.:.._�.._.,_—..�,,_ - --
<br /> I"�r r�ulti{sie ten;pdrary envir�snmer�tei v+e0s,prvvide addifional locaiion CASING(S)
<br /> inlprmati�n,d�itg sketCH,and t�alegy br�a sd��r�td pgga. biam�ler bepth N�a �ael In�sversize hol�? Rnnul�r s�s��:�initlaliy qtt�ult�J?
<br /> - --- _ _ _ ____ ; _ _
<br /> .-, 'Unk�,.�wn
<br /> Pf�OF�RYY C1WM�f#'�NAM�/CQMPANY NNM� _,__�iri.lrcrm------- �t�----_.N. ;_'Ysa ,tdr� ��l Yes ;_:IJo �
<br /> �.€A��r E✓rG.�s4�r _._.._
<br /> f'ro�rty trrmei'c rnalllnn adtlres5 il dlHyront than vrell IW:�Iion nd6resa nxliaafeU ahove ...._. ,�-- .- ..� ^...
<br /> -----in.irom _------ 10 ---.__,__ 1!. ;Yes ;;Ido ._;Vss �__W�r 'l�isknwwn
<br /> }'.o. Rox �+`�9 ,-,
<br /> - -----in.irom__ _ _. �o___.______._!t. 'Yus ;f�n ._;�es ;Cdtl i.._l�rM,P,vv�n
<br /> � �..kc� n�,o. �G�i'ly - - �-- - -- ---� ' _ -- _ ._ . __ _—v.�..�._.__
<br /> �E�,w+ �cA�ewoP�r�wa��
<br /> ---- -- -_ .. _ _ _._ 5cte€n irnm--.--,---..___t�-------N: C�heii Halc ir6m------..to._ /q
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<br /> W�I.L�WIJEIi'S t+IAM�/CC?MI�Ah�Y NAME -- - - --.-�:.,.. -- - ---- ____-� -
<br /> _ _ ._ -- _-__
<br /> �a��r O��Tt1UCT14NS ��
<br /> ;Y�il c ��.�`:�n�5ilirx3 addresn.i diflere�j!Ihan properry nNnn�s�Udres.,u,tli�atu=1 aBn�e� --;qpds/i5r6p Pire f�.�hrsok Valv�(s) _!13obria , '.�ill ;J�IVU l�b�IrUCti�ft
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<br /> = 7ype of 47bslructfons(LleScrib�). ---- -. - --- _._ _... _ _ _._
<br /> � [�bsirucl'rons removatr7 L_;Y� �--�No Oescribe_.__ -- . - ---- _--- --- --- ---..
<br /> - - ---- _ _�._.. m -�—�
<br /> ..�..d..��� -------� - - - -- ��---- - PUMP
<br /> GEOI.OGICAL MATEfl1A6 COLUA aAwDNssg 6w �ptlM T� _ hl�I f'r��rnt _f'resent,Ftemov+sd F'rior to�e�lin !(7th�r-_--- -____.------.-.
<br /> FORMA716N - � ;_, -----
<br /> if ntit hnt�wn,inslicatd��limalod 16rmation log ir�m nsarf�y we0 or tinring_ 7yU�--
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<br /> +� L,.�� �� � ��C,� - � s MF7W00 U3EBT0 9EA4 ANNULAi1 6PACE BE1'WEkN 2 GA�INI�£�,OR CA�INf pFad�Of��H6L�
<br /> � '�!-�'.' -;Mo Rnnular 5p� Exis*t� .1..� pa�e C�roulstl wlih`Frerrti�Pipo ` ,Ca;�;n,y f�arin�atidniW�+ir�oval
<br /> :Annuler�u
<br /> 7�,AL.�. Ih^ _ _ QRJy p .�. _ 1`� Cesin� i���tdr '�O�ir !'w�� f4�
<br /> �------iij.iram __.�_10._ .------- ----fl _i Weribra�ed !.;�1�srnuved
<br /> . � . �se � a n a,� ,� �°� _.
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<br /> - In.irpn5 -------to_. _-------.---N. i_;Pertnrplscf i.: �rr+uv�
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<br /> .�^���QA�►C.�'�,e—_ t• �1 _ . � � _ 7YUE ot pertor�tor
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<br /> 5.�.� `�6���� R�-8� � `�t vA�i�,roc� _ _ -.�~`
<br /> � ip�� We�c�varinnci�grantad irom th�Ml�hl tor ttd�w�ll7 ' ;Ye9 �tiNo 1'hlil
<br /> S�nc� W�•6R n li - ''{ _�0 - ___ _ _ �-,��_�� .,.��
<br /> L� �� (iH01JfiiNti MATEFilA6(5) (One bag at�mmnt s�s Itfs.,nne bag ol Genl2nife��0 Ibe,)
<br /> `-'��G..��.��.�� R�~�3 nf � D 6� "10 , h . . , o
<br /> GroullnyMaforlai�tW ��QS------ (�om__._d___ t�5_TQ _ t1.___._.---- Y�rds__-�---- 5a�a
<br /> ..�......_ -- .:.__ _ _ �E�vn�� rv&�'� �
<br /> ------ -------- from ----- �O._...----- it.--__....___. Ydtrls.___---- t�acln
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<br /> -------- trom_----- ta__---- fl`----- Yaid�------__ iiays
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<br /> QTM�R 4VELl�8 ANU��RIrJG�
<br /> _.._._ _ -
<br /> CJther unse�led atttl Untlyed WL�II @�bofing Oh Wfbnetly? �� �Ye5 ; '�ab Huw�t�eny7 ,._._, . .
<br /> . . .. .. _ . ._.._._ _ .._ . _..._. . .,.�_.v......,.-_.._.�
<br /> __- _. . . . - I.tBENB�D 4���013fi�A@4 CANTRACTOq C�q71FlCAfi1�N
<br /> H£MARKS,SOUF�GE 0F DATA,AIFFIGU6T1€g IN SEALING `�hi5 w�p or boring wa5 Ee�l�d in eecc+rd�nct�wi�h Minnesola pul�s;Chapler d7�5.tlye iMorrnatian��ntained iri this repc�rt
<br /> �. i�trua tc�Ih5 Baaf el my knowledge.
<br /> T,3. -�. - 'ia" wa�a.� 1e�e! G�3.
<br /> � !�o` �Jq�Rt,��1 �y•Z' -N�-'���--�1--Q --- --`��a��>��__------- -- -__ "3Zylv_----__.
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<br /> �•� .a ' Llr.ense�Husitteea N&mA Ltcens�Ur F��gl�f�e1lnn Nn.
<br /> � 'rq' ..��/+{•FJ?IEvEI loN'�� '��5*F�t_ ______`_'4•_.�'?D
<br /> `C'.+�3 } 3 '��-�_-- --__�_--_
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<br /> Csrtr/i�d F��apre�entallve 5iqnalure Cerllllerl Ftdp:Na, lJ[tfe
<br /> r�a��H �e� o�t+�.°rt�co�r H � ��� ��,r'' " ff —-r'1-a-�� �g�K�-r^�- --- ____ _-- ---_ -- _-----.
<br /> .. � C�- � `-t N�m�oi f�rt��an 5eolln�r WeN ar C�ortn�
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<br /> WC•01434�1� IbN5�15q ` y;t�R
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