Laserfiche WebLink
.... <br /> `b+/ELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> �' County Name WELL AND BORING RECORD � ���� � <br /> Minnesota Statutes, Chapter 1037 <br /> � Township Na e Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> f�. <br /> �� �� �� <br /> r GPS DRILLING METHOD <br /> LOCATION: Latitude _. degrees minutes seconds , <br /> Longitude . degrees minutes seconds = <br /> Cable Tool ! �Driven j,Dug <br /> � I Auger �otary ']Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number � <br /> DRILLWG FLUID WELL HYDROFRACTURED? ���I Yes �- o <br /> Show exact bcation of wel in section grid with"X". Sketch map of well location. ���r FROM ft.TO ft. <br /> Showing property lines, -- - <br /> � N �� � roads and buildings USE Monitorin <br /> ._ � _] g ,]Heating/Cooling <br /> �:.. __; _ � � � �..,,,,� '� -i Domestic Environ.Bore Hole ,J Industry/Commercial <br /> �' � �� ,Noncommuni PWS �] g '�Remedial <br /> ty [ Irri ation <br /> • J Community PWS ❑Dewatering ' i_ <br /> � � � CASING . HOLE DIAM. <br /> �� w , , e T Drive Shoe? �Yes �o ` <br /> �. ._,_____;_ _� �__ I 0�r ', ❑Steel I �Threaded �,�W ded ` <br /> 'hn�tiie �F� lastic � __ <br /> , ' -' � � 1 CASWG DIAMETER J WEIGHT <br /> S <br /> � in,to �� ft. ��0� IbsJfL � in.to� ft <br /> �—i M�ie—� ��j� <br /> in.to ft. Ibs./ft. �in.td"' ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. IbsJft. in.to ft. <br /> �� SCREEN_ OPEN HOLE ' <br /> � Property owner mailing a ress if different than well location address indicated above. Make �8� . FROM �ft. TO ft. <br /> ' (� y1 �* Type 9� '�t1� !R-q�� Diam <br /> '� ��"— ��i�'� � i� Slot/Gauze_ ___ ._���_ Length��__�� <br /> {,, t� Set between ft.and R. FITTINGS M <br /> P��Cl4i � SS��iV STATIC WATER LEVEL <br /> �^" ft. elow i_above land surface Date measured__�a� "-' <br /> PUMPING LEVEL(bel land surface) <br /> -% WELL OWNER'S NAME/COMPANY NAME I�S ft.after � � <br /> , hrs.pumping g.p.m. <br /> W�LL HEAD COMPLETION � � ' <br /> Well owner's mailing address if different than property owners address indicated above. �pitless adapter manutacturer `�-_ � <br /> ❑Casing Protection '�'(2 in.above grade <br /> �At-grade(Environmental Wells and Boring ONLY) T <br /> GROUTING INFORMATION,,.��-,,,/// <br /> _ Well grouted �es U No ,�,�(� <br /> Grout material Neat cement ❑Bentonite i]Concrete I�'IHi h Solids Bentonite <br /> from O to � ft. r � � ds. ags <br /> trom�to� ft. �� �����ags <br /> � GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from___ to ft. �,-_yds. ❑bags <br /> MATERIAL <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> _ �l�,�__feet ...�.: direction ��type <br /> Well disinfected upon completion Yes ,.�No <br /> PUMP <br /> j,,,�. <br /> � j _Not installed Date installed ,,..i � �„�� �.�� _ <br /> Manufacturer's name �� <br /> i/ - <br /> Model number HP�/�Volts � � � <br /> Length of drop pipe f��Ef ft. Capacity g.p.m. <br /> Type:. bmersible ❑LS.Turbine '�Ji Reciprocating �Jet ❑ <br /> ABAN ONED WELLS <br /> Does property have any not in use and not sealed well(s) [;Yes o <br /> VARIANCE <br /> Was a variance granied from the MDH for this well? [J Yes o 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 /> � <br /> Use a second sheet,if needed <br /> -- REMARKS,ELEVATION,SOURCE OF DATA,etc. u�Ai �todola Weli Drillicag Co,. IEIC• L7��L <br /> Licensee Business me �7 '.or Reg.No. <br /> i <br /> '-7. � -.�_ ��! <br /> 'e epresentative Si naty2 Date <br /> �.. ViiVi.:� �7W�� <br /> LOCAL COPY `� ('� �(�3 � NameofDriller <br /> ' � '"'f � HE-01205-08(Rev.5/02) <br /> � IC 140-0020 <br />