Laserfiche WebLink
MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD 8 9 410 6 <br /> Minnesota Statutes,chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> V. <br /> / ft. <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool ❑Driven- ❑Dual Rotary <br /> ❑Auger E Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes.❑No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. From ft.To ft. <br /> Showing property lines, <br /> N roads,buildings,and direction. USE IN, <br /> Domestic ❑Monitoring ❑Heating/Cooling <br /> -- -----1-----------1--. ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> L _ ❑Community PWS El Dewatering ❑Remedial <br /> ❑Elevator ❑ <br /> W E <br /> T CASING MATERIAL Drive Shoe? ❑Yes ❑No HOLE DIAM. <br /> �n Steel El Threaded ❑Welded <br /> 1/2Mile h r}5 ❑ <br /> 1 LLLJJJ Plastic <br /> T CASING <br /> s DiameterS Weight Specifications <br /> I 1 Mile I 4i in.To V ft. lbs./ft. in.To ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME 4 in.To ft. lbs./ft. in.To ft. <br /> in.To ft. lbs./ft. in.To ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN OPEN HOLE <br /> Make From ft. To ft. <br /> Type Diam. <br /> SIoVGauze Length <br /> Set between ft.and ft. FITTINGS <br /> STATIC WATER LEVEL ft. ❑Below ❑Above land surface <br /> Date measured Dry hole ❑Yes It'No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 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 /> ❑Pitless/adapter manufacturer Model <br /> ❑Casing protection ❑12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material From To ft. ❑Yds. ❑Bags <br /> Material From To ft. ❑Yds. E Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags - <br /> One bag94 lbs.cement <br /> or 50 lbs.bentonite <br /> - <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Well is feet direction from type <br /> Well disinfected upon completion? Ill'Yes ❑No <br /> • PUMP <br /> ❑Not installed Date installed <br /> Manufacturer's name <br /> Model Number HP Volts <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑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 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,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Licensee Business Name Lic.or Reg.No. <br /> r/ r <br /> Certified Representative Signature . Certified Rep.No. Date <br /> LOCAL COPY 894106 Name of Driller <br /> ID#52603 HE-01205-18(Rev.11/2022) <br />