well info - Laserfiche WebLink

Home Browse Search

M/NNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. �o��,tY Name WELL AND BORING RECORD Minnesota Statutes,Chapter 103I � 1��) �,/�'�� Township Na e Township No. Range No. Section No. Fraction WEWBORING DEPTH(completed) DATE WORK COMPLETED ,� n. GPS • DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds J Cable Tool []Driven �]Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location ❑Other 475 C)xfacr? ��J� `.7L� 55356 DRILLWG FLUID WELL HYDROFRACTURED? ❑Yes �No � , , Show exact location of well/boring in section grid with"X:' Sketch map of welVboring lo ation. [7CClt VI:LL Ce From ft.To ft. Showing propert lines, N roads,buildings,and dir ct�r} USE qDomestic �;Monitorin x � g [J Heating/Cooling __:___ __1__ ___L____:_ � r �� ❑Noncommunity PWS i�Environ.Bore Hole []Industry/Commercial [ i , 'S�, C Community PWS ❑Irrigation [;Remedial --'--- --'-- ---`-----t-- � ` — �. ; �Elevator ❑Dewatering �� _ _____ �' W , � E T � � - CASING MATERIAL ve Shoe? ;�Ye [�No HOLE DIAM ' --r - , - %--� \ Dr i l I � � �° ; Steel ❑Threaded [ Welded '/Mile ._' � ,��' :� .. � , , ' f .. ' Stif. � �j'Pla ❑ ; .----� -: 1 � ,,� � , ; ; : �'•CASING �. g `•_. _. .- � Diameter Weight Specifications , 1 /� C o C�t �1 Mile� . `�' in.To 1.77 ft. Ibs./ft. __ t3 in.Ta Jt.�tt � PROPERTY OWNER'S NAME/COMPANY NAME _in.To ft. Ibs./ft. �_in.To�ft `�'l�Jffk,.ZS �C@n {s�5 ��.ro ft. IbsJft. in.To n Proper[y owner's mailing address if different than well location address indicated above. � SCREEN OPEN HOLE Z/1�� R� iry�� {� ��n Make vVtui�,YV�l From_ ft To ft. L! �t Lan;; I,�kA, r'�� 5535� TYPe�t�inless steel Diam.— -- SlotlGauze_..___ �� .Length�� {.�,�� .} /k� � Set between ft.and ft. FITTINGS t� STATIC WATER LEVEL �� Measured from Ts_�y ft.�Below [l,Above land surface Date measured ��lrJ�l� WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 1�L� ft after 3 hrs.pumping St.r __g p m. Well/boring owner's mailing address if differeM than property owner's address indicated above. WELLHEAD COMPLETION T7�., �Pitless/adaptermanufactur�l�"��t�r Model _ ___ Li Casing protection f�12 in.above grade ❑At-grade ❑Well House � '��Hand Pump GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material }�I1t{)?1lrffrom�_To�r ft. __� j�Yds. �eags Material r�_�_To�_�.�ft. ❑Yds. ❑Bags HARDNESS OF Material From _To_ ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Dnvencasingseal From_ To Bags NEAREST KNOWN SOURCE OF CONTAMINATION � C Zc'?j/ �7 EQWT7 SC3 f� (3 � t ._.___ _._._ feet direction type r Well disinfec[ed upon completion? �'Yes [�No . C.`l.�'.Z� vCa.� 3OLL 3 q PUMP � ��2 �_I Not installed Date installed 1��1� clay tatl SOft � 17 Manufacturer'sname ��x��___ �� L f. Model Number HP__ r Volts cl�y �ray r�di� tt=� Lengih of drop pipe 1Q� _ ft. Capaciry _g.p.m ��!�'r��1 vacied �j� fi4 7t� Type:�Submersible ❑LS.Turbine f.i Reciprocating ❑Jet ❑ ABANDONED WELLS �;CB�T s�ru�/�;ravel br(�jj['� Tfj�[ji� 71� '1F{� Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE Was a variance granted from the MDH for this well? []Yes � o TN# WELL CONTRACTOR CERTIFICATION This well was drilied under my supervision and in accordance with Minnesota Rules,Chapter 4725. The intormation contained in this report is irue to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Ik�cz SCodol� C�eII 13�'ill�t't; Gos.�t�c. 1£�91 Licensee Business Name Lic.or Reg.No. • l 3�.. 1—�Z-24 ' -: . �..o .- - .- � � �� - ��`�,�"� GQrtifiAd Representative Signature f Certified Rep.No. Date .._ A, ,�� ,, �iy8i2 �"�E.'g8S[C.� LOCAL COPY � '� �"'`_� — — - .y ' f_f - Name of Driller � IC 140-0020 � � � - HE-01205-14(Rev.5'12) �