Laserfiche WebLink
. <br /> ► <br /> VvELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 2 Z 5 9 6 <br /> ���jl��;� Minnesota Statutes Chapter 103! <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> �runc� 1 i 7 c"� 7 �;� �.5;w ,��;:��. 1 i i <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLWG METHOD - <br /> ❑ Cable Tool ❑ Driven �� � �� - ❑ Dug <br /> 4 ` ' ❑ Auger �Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ � _. <br /> Y,�� Showing property lines, <br /> f - roads and bwldings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES RNO <br /> N :i <br /> , , i i . , - FROM e.co n. <br /> -,- -;- -,-- -,- �, <br /> � USE ❑ Monitonng ❑ Heating/Cooling <br /> � � i i ��-j-'-� rpomestic ❑ Communi PWS <br /> �Irrigation h' ❑ Industry/Commercial <br /> i i � i � O Noncommunity PWS ❑ Remedial <br /> w E� ❑ Test Well ❑ Dewatering ❑ <br /> i i i i <br /> i i i -r +/2M.1e CASING Drive Shoe? ❑ Yes Q-No HOLE DIAM. <br /> _i _ i_ _i_ _i_ � ❑ Steel ❑ Threaded aO Welded <br /> � � �� � �.� : �lastic ❑ <br /> 5 ~ ___""r-�.—� <br /> �1 Mile� "� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME � in.to_}_}_�ft. d'U� 111$./ft. 3�2 in.to#,�. <br /> _ , in.to ft. Ibs./ft.b =in.to�_�ft. <br /> 1 <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. <br /> SCREEN OPEN HOLE <br /> Make from ft.to ft. <br /> Type � Diam. _ <br /> SlotlGauze � Length �t'�� <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL � <br /> WELL OWNER'S NAME �l ft. C�below ❑ above land surtace Date measured���,� <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. .[�1 ft. after j hrs.pumping ,�.`j g.p.m. <br /> WELL HEAD COMPLETION <br /> ❑�itless adapter manufacturer �'JZ 1 L t'W!'ci��.0 Model _�^i��ii <br /> ❑ Casing Protection ❑ 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? D�es O No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement ❑ Bentonite ❑ Concrete D�High So�ids eentonite <br /> MATEf11AL from i 1'lilto�_ft. _�.�_ ❑ yds. E�bags <br /> from to ft. ❑ yds. ❑ bags <br /> tsd's1G�Y C:lz'tl� �rUi�11r1 ai-F.''C� � ��7t from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> s��lQ� Lla� ulu-,t�.s {��;�su j� �j�y �}� feet t1UY't,[i direction�y.�W��' :��m� <br /> Well disinfected upon completion? �Yes ❑ No <br /> �ax�tiy �`�.�'� jCIX�{ �@C��X� � V 11 PUMP <br /> ❑ Not installed Date installed j�1 v/ �j <br /> Manufacturer's name ��,� iC�j'„� <br /> � Modeln�� `I'WC� �1Z@ HP�.�� Volts �],;,y <br /> Length of drop pipe �('i 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 <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to the best of my knowledge. <br /> �t�5 .v�li i�rllli�g �717a <br /> � Licensee Business Name Lic.or Reg.No. <br /> t�. J . <br /> -- � . '%� ._,._,, �' , '�l�--- <br /> �-. <br /> Authorized Repr�e Signature � Date'+ <br /> Name ol Driller Date <br /> LOCALCOPY ��1 �96 `,. - : �-�_, _ <br /> HE-01205-06(Rev.9/97) <br />