HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
�o���Y Name WELL AND BORING RECORD 5 7 0 2 8 5
Hennepin Minnesota Statutes Chapter 103!
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
Orono 118 23 27 151 " 7/[5/95
�. ��, �,
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
1$7 6th Ave N ❑ CableTool ❑ �r��e� ❑ Dug
❑ Auger �-Rotary ❑ Jetted
Show exact location of well in section grid wj�"X". Sketch map of well location. ❑
/I� Showing property lines,
roads and buildings. DRILLING FLUID
N
Bel�t�
_� i i �_ �
- ___ _-_ '�
USE ❑ Monitoring ❑ Heating/Cooling
i i � i � Domestic ❑ Communi PWS
-�- -�- -�- -�- ❑ Irrigation ry ❑ Industry/Commercial
i i i i i-�_ "'`� �-t;.`� � ❑ Noncommuniry PWS ❑ Remedial
w E � ❑ Test Well
� � i i T : i� a .l?{�n ❑ Dewatering ❑
.t�,�—_ �7',-:7
� � _r r +/2IMae . . ; �,,.� CASING Drive Shoe? ❑ Yes J�No HOLE DIAM.
i _i_ _i_ _i_ � ❑ Steel ❑ Threaded ❑ Welded
_� � � � l , �3 plastic �7 �lued
S
�-1 Mila-�
CASING DIAMETEF WEIGHT j
PROPERTY OWNER'S NAME ���Gy � in.to 1�6 ft. Ibs./ft. s i�.t15�' n.
Phillip & Mar,� Hernande �, $ `�
in.to ft. Ibs./ft. in.to tt.
Prope wner's mailing address if different than well location address indic�e��Qqe. ____ in.to ft. __ Ibs./ft. in.to ft.
IB�� ounty Koad 6 - - � SCRE OPEN HOLE
Lang Lake, �t+i 55356 Make�$yC� from tt.to tt.
Type tQ1�gC0 in Diam.
SbVGauze Length
Set between ft.and ft. FITTINGS:
STATIC�(Vl�T�Fi LEVEL
WELL OWNER'S NAME ��� ft.�I below ❑ above land surface Date measured �/'15/95
- Same
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping 75 g.p.m.
WELL HEAD COMPLETION
❑ Pitless adapter manufacturer Model
❑ Casing Protection ❑ 12 in.above grade
❑ At-grade(Emironmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? ��[ Yes ❑ No
HARDNESS OF Grout Material I[►Neat ceryept ❑ Ber�pite ❑ Concrete ❑,kiigh Solids eenronite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO lL �
from 11 to �'f ft. ZS ❑ yds. 6l bags j
- from to ft. ❑ yds. ❑ bags
Tap Soil BTack 0 2 f�om to n. ❑ Yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION '�
Cilc1� Y�IZ.OW .Z 1� feet direction __ type
Well disinfected upon completion? ❑ Yes ❑ No �
Clay Gr�y� 19 69 PUMP g/11/95 �
❑ Not installed Date installed
Clay/Gravel Gray 69 93 Manufacturer'sname �Yers
Model number HP 1V�ts
Sxnd BZ'OWIl 93 11/� Length of drop pipe a� Capacity g.p.m. I
Pressure Tank Capacity
Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
Clay Grsy 114 117
ABANDONED WELLS �L,
Does property have any not in use and not sealed well(s)? ❑ Yes !u No
Sand/Gravel Mixed 117 151
VARIANCE
� Was a variance granted from the MDH for this well? ❑ Yes �No
WELL CONTRACTOR CERTIFICATION
Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,S4UflCE OF DATA,etc. The information contained in this report is true to the best of my knowledge.
�'' Stevens llrilling & Env. Serv. 86654
, , Licensee Business Name Lic.or Reg.No.
�, _ . . . . . ,_ � _.. ..._._.",._
Authonzed Representative Signature Date
Puu1 Swearing�r;
Name ol Driller HE 01205-05(Rev.1/95)
LOCALCOPY 570285