|
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH M�N AEND BORINI�G NO. ELL
<br /> co,,,,tYName � WELL AND BORING RECORD �, �,
<br /> �?i� Minnesota Statutes,Chapter 1037 ��5 Y,,,� � ,�,,� �
<br /> Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED
<br /> t3rcxio 117 23 �7 �,� ,, ,, 228 �� 5�-8-07
<br /> GPS DRILLING METHOD
<br /> LOCATION: Latitude degrees minutes seconds
<br /> Longitude degrees minutes seconds __ ❑Cable Tool ❑Driven ❑Dug
<br /> ❑Auger �Rotary ❑Jetted
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number ,I]
<br /> 741 tR7�h AL�I L7L �=L�0 �SJ�J'F DRILLING FLUID s WELL HYDROFRACTURED? ❑Yes No
<br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. """"t�it�
<br /> Showing property lines, From ft.To ft.
<br /> roads,buildings,and direction. USE
<br /> N �Domestic U Monitoring ❑Heating/Cooling
<br /> � � � � � _ � �!�(�/ ❑Noncommunity PWS ❑Environ.Bore Hole ❑IndustrylCommercial �\�
<br /> � --'----'--- ---`-- --'- �
<br /> � ❑Community PWS ❑Irrigation �_]Remedial
<br /> "' � � � ; ,� /� � ❑Elevator ❑Dewatering []
<br /> —'---—'--- --`-- ---`-- �`-1,/ �:
<br /> - W , , , , E p( 't CASING MATERIAL Drive Shoe? ❑Yes �'No HOLE DIAM.
<br /> --,-----;-- --�-- ---:-- T ? �
<br /> ; ; , , Miie e hreaded elded
<br /> �� � ���.�
<br /> St el ❑T W
<br /> , , , , � Plastic ❑ "
<br /> '' --�--- --�-- --�-- ---%- �
<br /> CASING
<br /> S � `�, Diameter Weight Specifications
<br /> �i Miie� ; �in.to�_ft. _�,.��Ibs./ft. ���*t!� �in.to�ft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./R ___ .�in.to�ft.
<br /> �+� �r��� in.to ft. Ibs./ft. in.to ft.
<br /> Property owner's mailing address if different than well location address indicated above.
<br /> SCREEN OPEN HOLE
<br /> � � �� Make .�A}1l49Afl From ft. To ft.
<br /> Type g����s $t'�_Diam.��
<br /> SIoUGauze n1 n Length
<br /> •
<br /> Set between ft.and ft. FITTINGS
<br /> STATIC WAT EL
<br /> - p Measured from
<br /> C75 ft. Below ❑Above land surface Date measured ��T
<br /> WELL OWNER'S NAME/COMPANY NAME PUM�f�Cy,�EVEL(below land surface) �.� ��
<br /> 1 Z�
<br /> ft.after hrs.pumping g.p.m.
<br /> Well/boring owner's mailing address if diNerent than property owner's address indicated above. WELLHEAD COMPLETION �
<br /> �Pitless/adapter manufacturer � � � '"''`�ifAodel
<br /> ❑Casing Protection �12 in.above grade
<br /> � ❑At-grade(Environmental Well and Boring ONLY)
<br /> GROUTING INFORMATION
<br /> Well grouted �Yes ❑No
<br /> Grout materials ❑Neat cement ❑Bentonite ❑Concrete ❑Other
<br /> From�To__,25L R � ❑Yds. ,�Bags
<br /> HARDNESS OF From 7�To��,tE1�8� ���Yds. ❑Bags
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
<br /> From 215 To��$_ft. �_ _ � J Yds. �Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> r �' �
<br /> �-'�$y yellaw gQlt � � _ �� � __feet �� direction ""'� ���ype
<br /> p ��' Well disinfected upon completion? Yes ❑No •�'.�.�....,
<br /> Cl� g� �lt 16 UMP . .
<br /> ) `'s
<br /> c ^ ❑Not installed Date installed -� � `
<br /> j� � ��� ""' `� Manufacturer's name ! � �--��� -'-
<br /> Model Number HP�Volts "� ✓���J
<br /> clay bro�m soft 210 21 � - � �
<br /> Length of drop pipe ` " `-�• ft. Capacity g.p.m.
<br /> ����=,a�1 1.r�n �C� ^t� �� Type:�Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
<br /> 1 �r � GI 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 TN#
<br /> WELL CONTRACTOR CERTIFICATION
<br /> This well was drilled under my supervision and in accordance with Minnesota Ruies,Chapter 4725.
<br /> The information contained in this report is true to the best of my knowledge.
<br /> Use a second sheet,if needed. �
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc.
<br /> Dan Stodola Well Dcillin� Ca., Inc. I691
<br /> Licensee Business Name Lic.or Reg.No.
<br /> - �'.
<br /> �� �� � '��
<br /> ReprEsentative ��� ure Certified Rep.No. Date
<br /> t�ick t�ooce
<br /> LOCAL COPY 7 5 �6 5 Q. — —
<br /> Name of Driller
<br /> IC 140-0020 HE-01205-70(Rev.6/06)
<br /> i.
<br />
|