Well Construction Record 8-12-24

Home Browse Search

Mr/VIVEJO IA UrVIQUt WELL WELL OR BORING LOCATION "" MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County' ame WELL AND BORING CONSTRUCTION RECORD i�) Minnesota Statutes,chapter 1031 i y�t 7 3 5 4 1 r Township Name Township,No. Range No. Secti n No. Fraction(sm.—.lg.) WELUBORING DEPTH(completed) DATE WO K COM LETED Cyr lt� 1 1' 3 ,, (;; 1 ft. ( i -�0Li GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool Driven ❑Dual Rotary • ❑Auger Rotary. ❑Rotasonic [ House�^Number,Stre t Name,City,and ZIP Code of Well)Locationt (` _ ❑Other ODD NA LV I L . hi.O"•r\"'" S,2 jL 1-1' _DRILLING FLUID - }{-` WELL HYDROFRACTURED? ❑Yes ❑No Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. "'j'1'}�)` t Showing property lines, From ft.To ft. N , roads,buildings,and direction. USE N Domestic ❑Monitoring ❑Heating/Cooling I I I I 1A`j -_-_1_._L 1 ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial ❑Community PWS ❑Dewatering ❑Remedial X ❑Elevator ❑ w i E T CASING MATERIAL Drive Shoe? ❑Yes [ -No HOLE DIAM. ❑Steel ❑Threaded ❑Welded 'h Mile Plastic ❑ I CASING ' g t Y I V Iv\ Dr, Dia Biter l i yU ft.Weight Specifications ] 0 1 1 Mlle I _ in.To lbs./ft. ! in.To ft. in.To ft. lbs./ft. /l in.Tot ft. ,PROPERTY O(WNER'S NAME/COMPANYrr_j NAME!y p N \1 lAct h (t u +0 I r-\ f t/ L - -4In.To ft. lbs./ft. n.To ft SCREEN—!� �' OPEN HOLE a n it Property owner's mailing address if different than well location address indicated above. 1 V Iy)SO . - , ` l' "" `/-�' ` -4 f , Make _ • . 1 From ft. To F ft. QtSI( �� J'F�! 1 IV Type ...74I().'1IY � Diam. 1^" x C e l s` r i h �� 55 3 �\ Set between I Length I `( t4�~ C/ a (J1 0 Set between } (� ft.and I;Si) .I ft. FITTINGS 3 ‘' 1 STATIC WATER LEVEL —* ? r ft. a Below ❑Above land surface g L Date measured 'Z 2 Dry hole ❑Yes N'No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ' ft.after. , hrsipumping q.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. ELLHEAD COMPLETION. �r 1'p4 vie h 1 Pitless/adapter manufacture,* er I' {V h Model ❑Casing protection 7-6 12in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INF. RMATION(specify be l o�itte,cement-sand,neat-cement,concrete,cuttings,or other) Il(SS _ Material�� r From To � ft. ❑Yds. Li Bags Material 120/1�1-4'tie- From 7 To h" ft. —3 ❑Yds. Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR FROM TO MATERIAL Driven casing seal From To Bags One bag=94 lbs.cement Lor,0 lbs.bentonit• �/` S�I '/'.,C f NEAREST KNOWNSOURCE OF CONTAy11NATION direction from 14-i1�� type ll is I2 0 A'1 {cf Y[D iKn— C 14 1 s Well disinfected upon completion? r Yes ❑No / 7 PUMP C 1 a lr• I c A o d /�Y S ' ❑Not installed DateeinNlsta�lled.163 r��{ t ( l-.. tt Manufacturer's name " `C� - ' ` r i { .)t l 1 l�Y tad I ` , 5 )�s ISO Model Number HP i/� Volts �3O Length of drop pipe H ft. Capacity ;.o g.p.m. • - Type:IX Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes [ •No VARIANCE ,.. Was a variance granted from the MDH for this well? ElYes No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725. Use a second sheet,if needed. The information contained in this report is true to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA,etc. D014 l,i S (\016', �PJC ki f '\ 10\ 1t}c I i. Licensee Business Name Lic.or Reg.No. rrr .ee L::, '. 1t'(3) ,4 Certified Representative Signature Certified Rep.No. Date LOCAL COPY 8 7 3 5 41 Name of Driller ID#52603 HE-01205-18(Rev.3/19)