Laserfiche WebLink
.�. .�-. <br /> b1�LL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 6 5 5 0 2 0 <br /> Minnesota Statutes Chapter f03/ <br /> Township Nam Township No. Range No. Section No. Fraction WELL DEPTH(completed). Date Work Completed <br /> _ , . ... . '..h:� <br /> i. /. v. <br /> House mber. treet Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> ❑ Cable Tool ❑ Driven ❑ Dug <br /> ❑ Auger ,�Rotary G Jetted <br /> Show exact locatio of well in section gri with"X". Sketch map of well location. Cl _ <br /> Showing property lines, <br /> � roads and b ildings. DRILLING FLUID WELL HYDROFRACTURED? [�VES�'NO <br /> � q`R N \_ <br /> � water <br /> i. i � i i � FROM ft.to ft. <br /> i -�- -�- -� - -�- -��' USE ❑ Monitoring ❑ Heating/Cooling <br /> ' � � i i Domestic ❑ Communi PWS <br /> ( _i_ _�_ _�_ _i_ X �� ❑ Irrigation Ty ❑ Industry/Commercial <br /> i i i i C7 ❑ Noncommunity PWS ❑ Remedial <br /> ! w e T � ❑ Environ.Bore Hole ❑ Dewatering ❑ <br /> ; i i i i I - <br /> r -r -7- -r- -r \ <br /> ' i i i i +/ZM e ,}� CASWG Drive Shoe? ❑ Yes �No HOLE DIAM. <br /> _i_ _ i_ _L_ _i_ � \,j ❑ Steel ❑ Threaded ❑ Welded <br /> � � � � �Plastic ❑ <br /> S <br /> �1 Mile� <br /> CASING DIAMETER WEIGHT <br /> 1 PROPEF3TY OWNER'S NAME t�. in.to�_p�Z ft. __ 2.{js Ibs./ft. �in.to_�� <br /> _in.to__ ft ._ Ibs./R (�� in.to�lf <br /> ' S- <br /> j Property owner's mailing address if different than well location address indicated above. __in.to ft. _ .___IbsJft. in.to ft. <br /> �, �) v� SCREENT�.� OPEN HOLE <br /> 'f� E Lake �t Make v��lil+'f�n <br /> from fl.ro ft. <br /> t�ayzata, MN 55391 Type�ia_inle�s steel Diam. <br /> SbUGauze �/11�1 Length �• ,� J. � „ <br /> Y <br /> Set between __�ft.and it. FITTINGS: <br /> STA IC WATER LEVEL <br /> WELL OWNER'S NAME �1� ft.�'below ❑ above land surface Date measured in—z�i� Q <br /> PUMPING LEVEL(below land surface)q <br /> Well owner's mailing address if different than property owner's address indicated above. _1 7� ft. after G hrs.pumping�.Q__ g.p.m. <br /> WELL HEAD COMPLETION �y,�j �,� a. <br /> �Pitless adapter manufacturer e�il1 yQS�e�.y���___ Model _,___ __ G <br /> - ❑ Casing Protedion___ _ _�] 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFOFMATION <br /> Wellgrouted? �Yes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement ❑ Bentonite ❑ Concrete �High Solids Bentonite <br /> MATERIAL from 0_ to�Q ft. 2.5 ❑ yds.� bags <br /> from�_to�__h�a t�.r$�_��7�yis. L7 bags <br /> Clay Z'$ $Q�t O from to ft ❑ yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION e-- � <br /> Sand r8 gOf� t�0 1z ���— _feet ��Gr� z' directiotA.��type <br /> Well disinfected upon completion? �Yes ❑ No <br /> CI$y broRn .4�1t i4Q 18 PUMP <br /> �, Not��5�a��ed Date installed 1-16-0 I <br /> Sand r$ S(�f� 80 Manutacturer's name _Aermntor <br /> Model numberT�50 _. ___ _ HP 1 .5 va�s_2 30 _ <br /> Length of drop pipe 14$� __ ft. Capacity __�g.p.m. <br /> Type: LJebubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet <br /> ABANDONED WELLS <br /> Does propeRy 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 �fJo TN# _ <br /> r <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,il needed 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 ot my knowledge. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> D�� _Stodola We11 Drj,_t 1 ino � �j� � <br /> Lic see Busin s Nam �or eg. o. <br /> �� !. <br /> �„�,- ,.-. <br /> 1-26-01 <br /> Authorized R sentative ignature Date <br /> _ nt►k Mnnr�g 1 t1.�9l4_.rtn <br /> 6 5 5 0 2 0 Name of Driller ' Date <br /> LOCAL COPY HE-01205-07(Rev.2/99) <br />