Laserfiche WebLink
MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORD 7 6 O 619 <br /> Minnesota Statutes,Chapter 1037 <br /> Towns i Township No. RangMe}No. Section��Nyyo. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> DRI <br /> LOCATION: Latitude degrees minutes seconds DRILLING M D <br /> Longitude degrees minutes seconds ❑Cable Tool ❑Drive{t E]Dug <br /> ❑Auger ❑Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number 11 <br /> IM5 Y Rd �� 15356. DRILLING FLUID J; -HYDROFRACTURED? E]Yes o <br /> Show exact location of well/boring in section grid with"X" Sketch map wel oring location. to From ft.To ft. <br /> S win roperty lines, <br /> N roads,buil d direction. USE omestic ❑monitoring ❑Heating/Cooling <br /> ------ ❑Noncommunity PWS ❑Environ.Bore Hole E]Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> --'-----'------`-- --`-- <br /> E]Elevator ❑Dewatering ❑ '-:.;# <br /> w ET CASING MATERIAL Drive Shoe? ❑Yeso HOLE DIAM <br /> -- <br /> ❑Steel ❑Threaded Welded <br /> h Mile lactic ❑ <br /> ----- --------- ---= <br /> I <br /> CASING <br /> s Diameter may' Weight ' n Specifications s +�{� <br /> —1 Mile 4 in.to�(ft. �l1b./ft. 49ft O in.to 30 t. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. lbs./ft. in.to 215ft. <br /> St t.T/S in.to ft. lbs./ft. in.to ft. <br /> ++77RC idress SCREEN _19bapW OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. <br /> 7407 tt Blvd. St/O Make From p ft. To ft. <br /> St i W_ M 5%26 Type LengtDamh <br /> 1G <br /> ii�iiia � Slot/Gauze +�© Length bs + 4# <br /> Set between ft.and ft. FITTINGS w <br /> STATIC WATER LEVEL <br /> Measured from <br /> ft. -low [:]Above land surface Date measured <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �{'� <br /> AAJI <br /> :.'< ft.after 1.5 hrs.pumping 50 g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION (} }-_ <br /> [Witless/adapter manufacturer l.3-T'ti�---t w `�+1�tfdel <br /> ❑Casing Protection [4IIIIIf2 in.above grade <br /> ❑At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMAjION <br /> Well grouted es [:]No <br /> Grout materials ❑Neat cement ntonite 7 Concrete ❑Other <br /> From To 30 ft. Yd . L—(— <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. an � ❑Bags <br /> MATERIAL From To ft. ❑Yds. ❑Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> cow soft 0 feet ...r direction --- <br /> softWell disinfected upon completion? es ❑No <br /> 23 601 PUMP <br /> ❑Not installed Date installed <br /> fp MA " <br /> "`1m �i 60 180 Manufacturer's name -Iry ZA ` _ <br /> soft 110 Model Number HP fts <br /> btam � iii <br /> ` <br /> Length of drop pipe � ft. Capacity g.p.m. <br /> 90/ti 2w 21 Type:[IjOubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> �! 1 li L.IN bi ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes o <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? '_]Yes o TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> Use a second sheet,it needed. <br /> The information contained in this report is true to the best of my knowledge. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Dan StallIDla WeU DrUILIng ce.0 I=. 16 <br /> Licensee Business Name Lic.or Reg.No. <br /> 17 l Gc <br /> Ce d nta a Signat Certified Rep.No. Date <br /> Noom <br /> 760619 Name of Drillerk <br /> LOCAL COPY -- <br /> IC 140-0020 HE-01205-11(Rev.3/07) <br />