Laserfiche WebLink
Metadata
Document management portal powered by Laserfiche WebLink 9 © 1998-2015 Laserfiche. All rights reserved.
WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUE WELL NO. <br /> F County Name WELL AND BORING RECORD , , , <br /> Hennep3n Minnesota Statutes, Chapter 1037 � � �� �¢ �� � <br /> ; ,Township Name Township No. Range No. Section Nq. Fraction WELL DEPTH(completed) Date Work Completed <br /> �; ' Orono i1T 23 1�i ,� ,� �, n _ + <br /> -' GPS ` DRILLING METHOD � <br /> LOCATION: Latitude degrees minutes _ seconds <br /> Longitude degrees minutes seconds ❑Cable Tool r Driven Dug <br /> ❑Auger �'Flotary Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number � �-� <br /> 1 b�0 Bohns L"ZI�LIC �,d� Or000 5391 DRILLING F�UID WELL HYDROFRACTURED? ,_]Yes No <br /> S exact location of well in section grid with"X". Sketch map of well location. b�n t on i t e FROM ft.TO ft. <br /> Showing property lines, <br /> N roads and buildings USE �����Monitoring �Heating/Cooling <br /> ' � � � � �Domestic [_J Environ.Bore Hole �L�Industry/Commercial <br /> ' --'--- --'--- --`-----'-- . <br /> �Noncommunity PWS �.._'Irrigation ,_ �Remedial <br /> �Community PWS ����Dewatering ] <br /> ' --'----'-----`-----`-- � <br /> CASING HOLE DIAM. ' <br /> .� w ; ; ; � E T Drive Shoe? f..�Yes �No � <br /> - � . � _Steel ���Threaded [�Welded <br /> '/Mile ' Plastic ` ] <br /> 1 `�� � CASING DIAMETER WEIGHT <br /> s ���� 11 <br /> � 1 Mile� -�� ���L -� �——in.to�_�ft. 4 Ibs./k. __�in.to 9 f1ft. <br /> i �Q <br /> _ in.to ___, ft. _ Ibs./ft �in.to��t. <br /> � PROPERTY OWNER'S NAME/COMPANY NAME in.to_____ ft. Ibs./ft. in.to ft. - <br /> ' �n j v --�-- .__.._ .. <br /> Robert �rC�i� 1'!OR}EB SCREEN OPENHOLE <br /> � f <br /> ., Property owner's mailing address it different than well location address indicated above. Make JO�TISOII FROM fL TO ft. <br /> � 565 Big Waoda ��� Type fdtg�tf1�R14 �tI, Diam <br /> - <br /> ` Chanha�sen, t�fAi 55327 SIoUGauze ____*�'1� Length __���_ �_ <br /> ___._ <br /> Set between ft.and ft. FITTINGS 1� � <br /> STATIC WATER LEVEL <br /> ' �3 ft.'�below �above land surface Date measure��3�Q6 <br /> PUMPING LEVEL(below land surface) <br /> WELL OWNER'S NAME/COMPANY NAME I g� ��� hrs.pumping �O ' <br /> ft.after 9.p.m. <br /> WELL HEAD COMPLETION �{� �. <br /> Well owner's mailing address if different than property owners address indicated above. �pitless adapter manufacturer �..J-�T�a,.7�.s-�.�s7�el <br /> _'Casing Protection �12 in.above grade <br />. At-grade(Environmental Wells and Boring ONLY) <br />� GROUTING INFORMATION - <br /> Well grouted �Yes _.]No <br /> Grout material ❑Neat cement I,__j Bentonite ❑Concrete�High Solids Bentonite _ <br /> from � to____! ��ft. 3 _yds. �bags <br /> from 3� to l��ft. �a't$ra��y�si��ags <br /> HARDNESS OF <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from to ft �yds. �,J bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> . C�I�y b ro�n .g(�f� ll �V `1.-r feet /`✓ direction . ��-fi��_�+�:^}ype <br /> Well disinfected upon completion Yes ��-No ��-.. "'+Jc..c��---� <br /> ��... G18� �r8y soft '�� �� PUMP <br /> [ Not installed Date installed �' •:.J'`� �--�� <br /> � L ,�:-�.�,s�.� <br /> sand g�$� .�(�f t �,v I�iQ Manufacturer's name �^.�.,, -._ <br /> � <br /> Modelnumber � HP�Volts =���� <br /> Length of drop pipe ��� ft. Capacity_ g.p.m. <br /> Type:[�Submersible ❑LS.Turbine ❑Reciprocating ;_i Jet ❑ <br /> ABANDONED WELLS <br /> Does property 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 TNN <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,if needed � <br /> ; REMARKS,ELEVATION,SOURCE OF DATA,etc. vV n S r odo i a �e Z 1 D r i 1 I in�; Cd� • 18�• G 1 7 Z�:,�. <br /> Licensee Business Name Lic.or Reg.No. � <br /> - �..�,�� �J� <br /> uy _ed Repre entative Si t Date <br /> Chuck pivare <br /> �OCAL COPY �� � � � � l�ameof�riuer <br /> HE01205-OB(Rev.5/02) <br /> - C 140-0020 <br />