|
. I
<br /> � MINNESOTA UNIQUE WELL
<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. '?�
<br /> �� Coun;y Name WELL AND BORING RECORD -
<br /> .. . . . �� �._, .-, f��
<br /> r?�n��ar;in - Minnesota Statutes,Chapter 1037- J J !� •_� �)
<br /> Township Name Township No. Range No. Section No. Frection WEWBORING DEPTH(completed) DATE WORK COMPLETED
<br /> �'Conc� ll7 ?_3 07 ,,cF. SF IVF, n.
<br /> GPS DRILLING METHOD
<br /> Latitude degrees minutes seconds
<br /> LOCATION: — -- q���
<br /> [I Cable Tool i]Driven r:�� ;,,,,
<br /> Longitude degrees minutes seconds �1 qu er Rotar �b,�'
<br /> House Number,Street Name,City,and ZIP Code of Well Location 9 I�� Y ��`'�
<br /> [I Other �r
<br /> T DRILLING FLUID WELL HYDROFR�CTURE ?, [�No
<br /> • t
<br /> Show exact location of well/boring in s ction grid with"X:' Sketch map qf welUboring location. i7�[ From ft.To ft.
<br /> - SlMowing property lines,
<br /> ` N roads,b ildings,and direction. USE �Domestic ❑Monitoring ❑(}}}���lgiatin��ic����
<br /> ` __L_ _ ____..�_ ...__ � ��Noncommunity PWS '� I Environ.Bore H01e`�]�iGstry/Commercial
<br /> i � ,p��� n []Community PWS _j Irrigation v ❑Remedial �
<br /> � --1--- � � � �� T '' ❑Elevator � ;Dewatering ❑
<br /> --'-----�-- ---`-- ' 9 .�
<br /> � ' W ; ; , ; E � b - ASIN MATERIA Drive Shoe? �]Yes �Na OLE DIAM.
<br /> � �`_ C G L H
<br /> --,--- --.-----�-- ---:-- T �.�.. �
<br /> , �]Steel ��Threaded ❑Welded -
<br /> ' , , , , Mile -
<br /> ,�
<br /> ., , , , , � '.-�-- ��,Plastic r J_
<br /> ' --�-- —�------�— --1— '-� —
<br /> CASING
<br /> � 5 � , . Diameter Weight Specifications
<br /> F--i Miie--� ,_.��____in.To 12� ft. _ Ibs./ft. R in.To J��.n
<br /> `5.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To tt. Ibs./ft. +,"k in.To 1���ft
<br /> c����n� �+r��,� in.To ft. Ibs./ft. in.To n
<br /> SCREEN OPEN HOLE 4
<br /> Property owner's mailing address if different than well location address indicated above. r
<br /> 23� 1��r±QI rf� Make �����-'�� From ft. To ft. t
<br /> ,�����'' �ttt ,�Z!}n Type stainl�ss St�Q� Diam.
<br /> �� SIoUGauze f{i'� Length_ (�t _
<br /> Set between ft.and_ ft. FITTINGS n
<br /> STATIC WATER LEVEL � � � ;
<br /> �
<br /> Measured from
<br /> 7��-` ft.j�.Below ❑Above land surface Date measured '�- � 1
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
<br /> $� r
<br /> -� ft.after 7 hrs.pumping �A� g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION 74,.i
<br /> Pitless/adaptermanufacturerT`�"��lt`r�c�t#�r Model
<br /> r'Casing protection [�+12 in.above grade
<br /> �1 At-grade �]Well House ❑Hand Pump
<br /> GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement concrete,cuttings,or other)
<br /> Material��CYSt(]F41t�From_ �To��ft _� [j Yds. [�Bags
<br /> Materialtlilt'llt"A�I tf'�r�r�,__.��_To_�,Z�ft. [,Yds. f JBags
<br /> + HARDNESS OF Material . From To R. [i Yds. [J Bags
<br /> ; GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
<br /> Driven casing seal From To Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> CI$j �lE?�TOLvT "t�„°�_� � �7 f_.... feet = _� direction �-.'d.'' :• tYPe f
<br /> 7 Well disinfected upon completion? es ❑No !�i � t,,:�� .-
<br /> "`.`�eZ`"��r C1.�> t.ar��' T';ei��L�t`! �� �i� PUMP
<br /> ❑Not installed Date installed ��l��t tx __ _
<br /> C1F3.�,S<`2��t� �C`3jr K'1e��.LtE�3 ��Q ��` Manufacturer'sname C;�.���F� ____ _
<br /> �_a �r�� ���t �,�� �'� Model Number HP ��1 Volts ,
<br /> FIL: ¢
<br /> Length of drop pipe l�l 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)? i_j Yes � � o
<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,i1 needed.
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc.
<br /> �n �tc���ol� '�?�11 I�rillin;; ';�,. ���c. �'��'1
<br /> Licensee Business Name �-�--- Lic.or Reg.No.
<br /> .�
<br /> � ;'�f� �'/ 1-5-1.5
<br /> GeEtified Representative Signature Certified Rep.No. Date
<br /> ., �� . � ; F.� �'c�h SLcs�ol�±
<br /> i�CA�.CQPY I� .�` � .�lJ Name of Driller
<br /> IC 140-0020 � � �
<br /> HE-01205-14(Rev.5/12) ��
<br />
|