|
MINNESOTA UNIQUE WELL
<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
<br /> County Name WELL AND BORING RECORD � � �5 Q 3
<br /> Iiennepin Minnesota Statutes,Chapter 103I
<br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED s
<br /> Orono 117N 23W 14 ,� ,� S$� 152 h Feb. 28, 2007
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds
<br /> Longitude degrees minutes seconds ]Cable Tool [j Driven ❑Dug
<br /> -- J�Auger �Rotary ❑Jetted
<br /> - House Number,S[reet Name,City,and Zip Code of Well Location or Fire Number ��
<br /> 1850 Shoreliae Dr, WByZaCB DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �No
<br /> Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. �entonite From ft.To ft.
<br /> Showing properry lines,
<br /> N roads,buildings,and direction. USE
<br /> s . �Domestic ❑Monitoring ❑Heating/Cooling r,
<br /> __L____�__ __L___L_ ���� ��_-�.._.-� ❑Noncommunity PWS ❑Environ.Bore Hole []Industry/Commercial �
<br /> ❑Communiry PWS ❑Irrigation :�l Remedial
<br /> � --'--------- --;-----'- ❑Elevator ❑Dewatering ❑
<br /> W � � � E ...--• ---�-�.,.-.-,�.�.....�..a,,,,,,,,�....,.s,,,,�.,,,.,..,�.,..,...V.... „ -� ..
<br /> ; , T _.__ _�,_„�,n,_,,,�,,,.,,.,e,,,,,,,,,,,._,.ro�__..,,_ CASWG MATERIAL Drive Shoe? ��Yes �No HOLE DIAM.
<br /> --�--- ------- � � �
<br /> � � �
<br /> I ❑Steel ❑Threa d ❑Welded
<br /> �� , , 'fe Mile �
<br /> ; � � i, Plastic � e�
<br /> � --�-----�-----�-- --�-- ^.
<br /> 1 u
<br /> ; ; ' ' � CASING
<br /> g � �-'�.�, ;,,� Diameter Weight Specifications
<br /> ,L-� 7 A�f
<br /> �1 Mile� l�e'� � t.�-,!�,''_Q � in.to ��" ft. IbS./ft. `� Il1.t0�O ft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME ! in.to ft. Ibs./tt. 6• in.to 1 S�
<br /> Tro.y Broi t ziaan in.to_ ft. Ibs./ft. in.to n.
<br /> Property owner's mailing address if different than well location address indicated above.
<br /> SCREEN OPEN HOLE
<br /> 1860 Shoreline � Make apCQ From ft. To ft.
<br /> �ByZStB� MN 55391 Type Diam.
<br /> Slot/Gauze t Length__
<br /> Set behveen 147 R.and iSZ ft. FITTINGS k packer
<br /> STATIC WATER LEVEL ground
<br /> x 2 Measured from�'J�j'F��
<br /> q ft.�Below �,�Above land surface Date measured `�� �-"f�
<br /> _ WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> Tray Brc►itz�an ft.after hrs.pumping �� g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION „
<br /> y�Pitless/adapter manufacturer �g�s Model 4
<br /> ❑Casing Protection ❑12 in.above grade
<br /> ❑At-grade(Environmental Well and Boring ONLY)
<br /> GROUTING INFORMATION
<br /> Well grouted �Yes ❑No
<br /> Grout materials ❑Neat cement�'Bentonite ❑Concrete ❑Other
<br /> From 8 To �� ft. � ❑Yds. L�Bags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. ❑Yds. ❑Bags -
<br /> MATERIAL
<br /> i From To ft. ❑Yds [�Bags
<br /> CZfl� �/@llO�i Q 13 NEAREST KNOWN SOURCE OF CONTAMINATION�VGr r�i seWer
<br /> ___ feet _ direction ____ type
<br /> 8811d gI'&y 13 32 Well disinfected upon completion? �Yes ❑No
<br /> PUMP
<br /> C18q grH51' � 3z 11� ❑Not installed Date installed � -"� ! �� � �� ��
<br /> t.�`, , 1 f�
<br /> Manufac[urer's name ��� -
<br /> sand bTOiiFI ;i� I21 Model Number HP Volts_
<br /> �,(/ � �
<br /> Length of drop pipe s.i�✓ ft. Capaciry g.p.m.
<br /> C�.BY �t 88t1(� brawu 1�1 1•FS Type:[1�Q Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
<br /> ABANDONED WELLS
<br /> �and & gravel $T8� 1�5 1 rJ 2 Does properry have any not in use and not sealed well(s)? ❑Yes �No
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? ❑Yes �No TN#
<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,il needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc.
<br /> Stevens Dril2ing � Enviroriaental Svc �2?.55
<br /> Licensee Business Name Lic.or Reg.No.
<br /> :
<br /> .. ,.,. ,,� t.
<br /> ` _ -_�-x6�s.�. �
<br /> . ��-�/�.�
<br /> Certified Representative Signature Certified Rep.No.� Date
<br /> Rar�dq Johnson
<br /> LOCAL COPY 7 ��5 0 3 --
<br /> '
<br /> Name ot Driller
<br /> IC 140-0020 HE-01205-10(Rev.6/O6)
<br /> �/ 1
<br />
|