Laserfiche WebLink
R - . <br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUEWELL NO. <br /> �: County Name WELL AND BORING RECORD <br /> � Minnesota Statuf�s;"Ch"�'�f 1037 ��' 5�f�� <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed � � <br /> �, �, ,, �� 145 f� �2�� <br /> GPS DRILLING METHOD <br /> -. LOCATION: Latitude degrees minutes seconds � <br /> f`���Cable Tool '���Driven ��Dug <br /> ¢� Longitude _ degrees minutes seconds - 'Auger �Rotary ' �;Jetted <br /> House Number.Street Name,City,and Zip Code of Well Location or Fire Number <br /> DRILLING FLUID WELL HYDROFRACTURED? �, ,Yes � � o <br /> Show exact location of well in section grid with"X. Sketch map of we!I I cation. �rej' FROM ft TO ft. <br /> Showing prope y li s, <br /> ;� N L roa��d il� USE �Domestic O�En iron!Bore Hole �'Heating/Cooling 6 <br /> ♦ , <br /> � J J ' � ���J � �Noncommuni PWS L.]Industry/Commercial ; <br /> �� , ; � (� . ty ❑Irrigation �]Remedial <br /> ; , ; , , *-+� �1 z L Community PWS [�Dewatering �" - <br /> �-^ CASING HOLE DIAM. k <br /> w e 1� Drive Shoe? '�'��.Yes �No <br /> � ' ' ' �^�-�------� �Steel ��`Threaded �Welded <br /> , . _� T ;� _.. � <br /> � : ; : - .-- ,_ - <br /> � 'h Mile � Plastic _ <br /> LJ <br /> �,� ' ' � � 1 CASING DIAMETER WEIGHT <br /> � I S ; � • q� �� *"� <br /> � .�tL� � � in.to i�" ft ���� Ibs./fl. in.to �ft. <br /> �-1 Mile—� t� (�� �— j <br /> �� in.to it. IbsJk. �+�__in.t�"'f� ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to fl. <br /> SCREEN OPEN HOLE - <br /> Property owner's mailing address if different than well location address indicated above. Make FROM ft. TO ft. <br /> � 1844 Wayztta ���s � �1J TYpe—� —_ Diam. <br /> � i w� � C��� SIoUGauze ���� Length�_.._ ._ _ <br /> Lxi � a Set between_, ft.and ft. FITTINGS <br /> STATIC WATER LEVEL <br /> � ft.�_ elow ❑above land surface Date measured �J—llJ <br /> �� r PUMPWG LEVEL(below land surface) <br /> � WELL OWNER'S NAME/COMPANY NAME �� q . �/� <br /> ft.after 4 hrs.pumping____ '►V g.p.m. <br /> WELL HEAD COMPLETION .yj <br /> Well owner's mailing address if different than property owners address indicated above. �'7�pitless adapter manufacturer �iu��t� ._ Model _ <br /> �f� <br /> _!Casing Protection �2 in.above grade <br /> '��]At-grade(Environmental Wells and Boring ONLY) <br /> GROUTING INFORMATION,,,���,,,,,,ff(��� <br /> Well grouted �es , ',No <br /> Grout material J Neat cement []Bentgon�itye �_J Concrete�High Solids Bentonite <br /> from � to -�N ft. .7 �,yds. 'I'3etlags '� <br /> from � to�J4 ft,�tu�ai ����. �lbags `� <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft �_�,yds. �,�ba s <br /> MATERIAL 9 <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> L'I8�► yello� a�c►ft 28 _ � feet .�f.! direction 'type <br /> Weli disinfected upon completion �es �No '�',�,y._t:_.`�.>_,>} <br /> — ...._,..,_ . _. <br /> C18y gCSy BOft ZS iZO PUMP : <br /> -�.Not installed Date installed_ Zt+�`1L."VJ � <br /> Manufacturer's name a <br /> : asnd tan soft 3.ZQ t45 Ae�at�€ _ <br /> Model number ___ HP__���oRs�___ <br /> Length of drop pipe Z0� ft. Capacity g.p.m. <br />�'`��� Type:�� - Submersible ❑LS.Turbine ❑Reciprocating ❑Jet <br /> �� <br /> � ABA ONED WELLS <br /> Does properry have any not in use and not sealed well(s) [.,!Yes j_. o <br /> VARIANCE <br /> Was a variance granted 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 /> Use a second sheet,if needed ����'1 . <br /> •• REMARKS,ELEVATION,SOURCE OF DATA,etc. l/IRiJC�OlII �elLnrilifc,� ��S ILIC• �7i7L <br /> Licensee Business Name Lic.or Reg.No. <br /> a' <br /> ut r� pres tativeSignat�re �'��� Date � <br /> Chuck i+�oore 12-5-03 � <br /> 7 ��� �Q Name of Driller � <br /> LOCAL COPY i <br /> - � H607205-OB(Rev.5/02) <br /> IC 140-0020 <br /> .� <br />