|
' S'���,1'. . . . .
<br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
<br /> WELL RECORD .- �� �
<br /> County Name � ("� � �
<br /> t , ,� : <<, �. �� Minnesota Statutes Chapter f031
<br /> r-
<br /> � ��� :
<br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion
<br /> fl.
<br /> ' /.: fy" !7 � �C'1,1/'1.,,�'Vl. : c,,�l. .�.j �� �� � �-
<br /> Numerical Street Address or Fire Number and City of Well Location DRILLING METHOD
<br /> r -
<br /> � CableTool I I Driven L] Dug
<br /> ,i `j-,i ;!, ,j<'1 i i;' l ❑ Auger �.Rotary C Jetted
<br /> Show exact location of well in section grid with"X". Ske'tch map of well location. C]
<br /> Showing propertylines,
<br /> N �,� roads and buildings �� DRILLING FLUID
<br /> I i y _1_ /� j 1 i 7 �._ `;:
<br /> --r- 7- - i � � ± 1 .� 'vJ"'
<br /> � ! ,
<br /> i � � � .--._, � j USE
<br /> �-�- -;- �- �' � �; �t �Domestic ❑ Monitoring ..J Heating/Cooling
<br /> W � E , j � �Irrigation L I Public Industry/Commercial
<br /> _1_ _i_ _'_ __ T � J} � � C Test Well ❑ Dewatering
<br /> � � i I �C 5 �,. � `` ^'�
<br /> ' f-mc � ��,,; i CASING Drive Shoe? � : Yes .: No HOLE DIAM.
<br /> � , I E
<br /> --i- �- - —�" 1 ! ❑ Steel Threaded :] Welded
<br /> �_�m,le� t ,`?.i � Plastic i..l
<br /> ' CASING DIAMETER WEIGHT
<br /> r
<br /> PROPERTY OWNER'S NAME ��in.to ) i'= tt. ,� ..�2. Ibs./ft. �in.to�ft.
<br /> - _ � in.to ft. Ibs./ft. ��in.to�+ :Wt.
<br /> Maili'ng address if itterent than property address indicated above. in.to tt. Ibs./ft. __in.to_ft.
<br /> / r, G, r �. ;'i'. , " s j fl� G+' SCREEN ` OPENHOLE
<br /> � �_� J � /y ` - Make�', .��!� � from ft.to ft.
<br /> ��J r .„ / �F�r,'-'r� �.�1 � 1 ,t�/J� , �..J r ? !J � TYPe t'�`,. L_... Diam. [/�% _ .
<br /> ;� � ' SIoVGauze �7 r� Length �(
<br /> Set belween�_) !_ ft.and ,Z,�D ft. FITTINGS: � �
<br /> STATIC WATER LEVEL
<br /> FORMATION LOG COLOR HARDNESS OF FROM TO ` J"� ft. below � above land surtace Date measured r '"i
<br /> FORMATION � �C. r P�
<br /> PUMPING LEVEL(below land surface)
<br /> � ,, :" � � 1 f` ft. after � hrs.pumping Zf` fl.p.m.
<br /> "'.-/
<br /> ` WELL HEAD COMPLETION
<br /> � t ;�_�e" r � � r ` / �.�Pitless adapter manufacturer L,.,1� � 3.`� Model �" 7 f .. �"'"
<br /> �� ! I 7 Casing Protection
<br /> ' ' GROUTING INFORMATION
<br /> �,.. � �`'-«,.... �i �. ,{'
<br /> Well grouted? �Yes C No
<br /> { „ J �;'� � } � Grout Material L,�[Neat cement ❑ Bentonite
<br /> �f from v„ro Tr ri. L I yds. ❑ bags
<br /> ! from to ft. ❑ yds. ❑ bags
<br /> r ��{�, y( ,�j;., r � . / f} �d a from to ft. ❑ yds. ❑ bags
<br /> NEAREST SOURCE OF POSSIBLE CONTAMINATION
<br /> ,r�! �' r. � ry.-- / ,� ✓ � � .)� � S feet E direction _,���.._..,��J tyPe
<br /> ♦,'� � Well disinfec[ed upon completion? �Yes ❑ No ;� - ��
<br /> PUMP
<br /> C; Not installed Date installed '�� �` � �'t
<br /> ' Manufacturer's name -i�T,... i`_..aG..
<br /> Model number� �& �._ HP '/� Volts � � J
<br /> � Length of drop pipe� n tt. Capacity 1 � fl.p.m.
<br /> f� Pressure Tank Capaciry ) a > �r T�, �
<br /> Type: C�6ubmersible ❑ L.S.Turbine ❑ Reciprocating _ Jet ❑
<br /> ABANDONED WELLS
<br /> Not in use and not sealed well on property? ❑ Yes C3xVo
<br /> WELL CONTRACTOR CERTIFICATION
<br /> This well was drilled under my jurisdication 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 /> Useasecondsheet,ilneeded % L' !:�.;,�''`f c:i l v" / fc
<br /> �
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee usiness Name ` Lic.or Reg.No.
<br /> �.'"'_: ;
<br /> �, <� � r �: ,� r� �- �r .�
<br /> 'Autfiorized Representative Siganture Date
<br /> �'d /,;;�: ,,�. t! �: i .�
<br /> Name of Oriller Date
<br /> LOCAL COPY � � � d� � HE-01205-03(Rev.9191)
<br />
|