Laserfiche WebLink
: • �� <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH M/N AEND BOR/N��G NO. ELL <br /> ' co��tiName WELL AND BORING RECORD �-7�$ �� <br /> ��pia Minnesota Statutes,Chapter 103/ A <br /> Township Name Township No. Range No. Section No. Fraction WEWBORING DEPTH(compleled) DATE WORK COMPLETED <br /> t�rono I17 23 08 � N�, N�1 ,, n. <br /> GPS � DRILLING METHOD <br /> LOCATION: La[itude degrees minutes seconds . i _ . <br /> Longitude degrees minutes seconds � .Cable Tool �Driven i Dug <br /> �_j Auger �otary ,�:Jetted <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number �-�. <br /> 91S Farr�ood Rd, SrCOCK� 5535b DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No <br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring locati�. ���C From,___ ft.To_ ft. <br /> Showing property�es, - --- — <br /> N roads,buildings,and dir tion. USE �Domestic ,.�Moniroring �'_�,Heating/Cooling <br /> ' ___ __ _ __ ' �I Noncommunity PWS ',-_Environ.Bore Hole �_�.Industry/Commercial <br />< < � ��� - <br /> S;-. �;Community PWS I�Irrigation ,_ 'Remedial <br /> --�---- ---- -�- -- >-- � � � L.Elevator � ]Dewatering `�_-] � <br /> � `/'/ E � �� -� CASING MATERIAL HOLE DIAM. <br /> ; � ; '�, � � ��. Drroe Shoe� _ Y s I No <br /> -�-- -- -- � --%-- T "i� <br /> � e <br /> � � I �"`-- ry- I�Steel ���Threaded �_�I Welded <br /> , , 'h Mile �,.s 4° � <br /> �': <br />.. ; ; , � , 7 ��Plastic <br /> [] <br /> �-- - 5 � -�-- :. <br /> _ ! CASING <br /> � � "'�� Diameter Weight Specifications <br /> ----�'. <br /> i i nn�ie� "T in.to 471 }t. �1 Ibs./ft. _ �in.to_ <br /> 2 <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to_ ft. Ibs./ft. �''�in.to <br /> ,S <br /> 5����iC' & �At�;�Yf�� I�+� " _ in.to ft. Ibs./ft. in.to ft. <br /> ,.i.r,. <br /> PropQerty owner's mailing address if different than well location address indicated above. <br /> SCREEN OPEN HOLE <br /> ��' �47.)�t�l ���tC7[iCS22 .i3�� Make �� � _ From —__ft. To_.. _—_---ft. : <br />.. � Yti$�T$$��� r��Rv 55391 TYPe stainles$ '$�,y -- Diam.-- --.—.-- <br /> Slot/Gauze _n�n . Length /�����j_ <br /> Set between ft.and it: FITTINGS <br /> STATIC WATER LEVEL <br /> � n� Measured from '!C'♦ <br /> � ft.'J�Below '� �Above land sur(ace Date measured .T'X"1� <br /> WELL OWNER'S NAME/COMPANY NAME P6hpP}[VG LEVEL(below land suAace) � L^ <br />�i G�t3 c�tie <br /> ft.after hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> � �Pitless/adapter manufacturer �, ' J�.._�,�.�._r�.��� • Model <br /> ❑Casing Protection _________ �12 in.above grade <br /> `�At-grade(Environmental Well and Boring ONLY) <br /> GROUTING INFORMATION <br /> Well } � � �No j� / x <br /> Grout�'�I��cement Lf�entonite�oncrete �Othe1'► <br /> From To _ft. '"Yds. L i Bags <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To __ft r�'Yds. "Bags <br /> MATERIAL <br /> From To____ft ❑Yda ����Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> � cl�y ye�Ic� soft 0 28 � >, <br /> f- , <br /> -� feet 4� direction �-� �� . - - �� type <br /> - .}p p� Well disinfected upon completion? ['�Yes []No �""� � � � �;�- -' <br /> �._�....... . . <br /> C�A�I.Sa� �L�S� .�OfC L(7 �C7t3 PUMP i�. <br /> �vl�� �r� ���t ��� ��� �]Not installed Date installed ` � ��, � ���� <br /> � <br /> . <br /> Manufacturer'sname '�� �" -= .,-��->- .��= -' <br /> j <br /> Model Number r�� HP � ��--'+ Volts -F `�J <br /> coacse sandstor� �ahite saft 297 3Q8 " <br /> Length of drop pipe l...T��D ft. Capacity g.p.m. <br /> Type:I, �.Submersible �]LS.Turbine �;Reciprocating �. I Jet �-l'�_ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? L;Yes �No <br /> VARIANCE <br /> Was a variance gran[ed from the MDH for this well? �-l�Yes �T�No 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,il needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. caV[i JtQ(lOiaWeI2 �til.lin� Cc>,. 1jZC s ���1 <br /> Licensee Business Name Lic.or Reg.No. <br /> � ,� _:�l�-, f 7 <br /> C 'ie e resentative Signature ` Certified Rep.No. Date <br /> G�?L�C�CC ?�t@ <br /> LGCRL COPY � 7� � �> � <br /> Name of Driller <br /> IC 140-0020 � HE01205-12(Rev.12/OB) - <br />