well info - Laserfiche WebLink

Home Browse Search

�� r—., MINNESOTA UNIQUE WELL WELL O�E�RI�,LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORWG NO. ;� County Name WELL AND BORING RECORD 7 919 9 7 Minnesota Statutes,Chapter 1037 Township Name Township No. Range No. Section No. Fraction WEWBORWG DEPTH(completed) DATE WORK COMPLETED � �� fl. ' GPS DRILLING METHOD ' LOCATION: Latitude degrees minutes ____ seconds ___ u� Longitude degrees minutes seconds f^CableTool I �Driven —— — — - — -- Auger �otary House Number,Street Name.City,and ZIP Code of Well Location Fire Number ❑Other I�� J.i,j'� �y l/f.V[1V �5.771 DRILLING FWID WELL HYDROFRACTURED? ❑Yes No Show exad location of well/boring in section grid with��X" Sketch map of well/boring loc ion. ��lit�' From ft.To ft. Showing property nes, N roads,buildings,and dir tion. USE r�Domestic ❑Monitoring �1 Heating/Cooling �,� __L__ ._�_. ___�__ ; ,` :.]Noncommunity PWS ❑Environ.Bore Hole U Industry/Commercial ---'-- : ; ; ; ; � �Community PWS [�Irrigation ❑Remedial ��' � --'--- --;------�-----'-- []Elevator ❑Dewatering ❑ '- < w ; � ; ; E T ASIN 0e a HOLE DIAM. , , ' r * Q 4y MATERIA Drve Sh Yes I�'No �;� s C G L i � :� ; ; ; � �r�v ri ❑Steel ❑Threade [�Welded � � , , , h_-M��le � �plastic ❑ � ------ ------ - � � 1 : CASING S � Diameter t Weight Specifications ��Mile� �1 ,.,�.�._.:a,,, `f-,..,J/�.. . � in.Ta iL7L ft. Ibs./ft. 8 in.To__ �It. PROPERTY OWNER'S NAME/COMPANY NAME � in.To _ft. Ibs./ft. __ � in.To +�t �� J�� __ in.To _ _ _ft. Ibs./ft. in.To ft Property owner's mailing address if different than well location address indicated above. SCREEN��r� OPEN HOLE �. 1'fIV1 l�f,.��\2.0 M. Make �iii�4Al 17 W �7L7VLC1.LI7C Sta -- — From_ ft. To ft. '� T e �ain�ess �� Diam. � ' � YP — — — -- ------- ---— �� SIoUGauze ;�� __ _Leng[h� � {}t Set between ft.and ft. FITTINGS „ � ` STATIC WATER LEVEL Measured from {� �w�Q�� ;�' "� tt.�'$elow [_Above land surface Date measured "' �'� �•' WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 1� ft.after_ _ V" hrs pumping �"� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION —�e t��c� ,�j PiUess/adapter manufacturer �i13_ ._ __��Model 3 ❑Casing protection ____ _ �{2 in.above grade -� ❑At-grade []Well House !�Hand Pump � � -' GROUTWG INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Matenal_�t�C�rom V To_ JV _ft J ❑Yds �'Bags Matenal ffi�IiC�J. �2rJf�_�_To�fL ❑Yds. ❑Bags ' HARDNESS OF Matenal . _____ _From____,_.._To__ _fL ❑Yds. ❑8ags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnven casing seal From __To__ Bags NEAREST KNOWN SOURCE OF CONTAMINATIO/N �� `'�� t � � /,�'�-�r feet �`� direction ��--^��-^�'` type tr Well disinfected upon completion? ,SC�Yes �No .� Cl� �L�1{� �Qlt Z 27 PUMP �� j! �� ❑Not installed Date installed __�`_ �� .__ _ � ��'Z Manufacturer's name .�'f►�tAA�O/' C�� g�/UiiJi WC�.L3.� 2s3 I6i Model Number _ HP__3___Volts__2�____ Length of drop pipe iGV __. _ft. Capacity _ g.p.m �te� �� 6�Eli.� lb3 1/V Type: Submersible (J LS.Turbine [�Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes o VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# 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. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Dc�_S�4ct��tt ��Dcil� CO.��_�Ei91_-- Licensee Business Name Lic.or Feg.No. �'.�' �i-ia-12 rfied e � S'e'ntative Si ure Certified Rep.No. Date � LOCAL COPY — __ — _ —— —� �� .�. 7 919 g 7 Name of Driller IC 140-0020 HE01205-13(Rev.11/10)