HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD �g 5 01 �
Hennep i n Minnesota Statufes Chapter 1031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
Orano 11? 23 4 ,. �. ,. 181 n 1Q/9/96
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
n�fn ❑ Cable Tool O Driven ❑ Dug
27G�J .�?���r8�� Lane Or�nfl ❑ Auger C�Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
ro3ds and buildings. DRILLING FLUID
" Bentonite
� � � �
-,- -,- -,-- -,- G., �
USE ❑ Monitoring ❑ Heating/Cooling
i i � i C�Domestic
❑ Community PWS ❑ Indust /Commercial
i i � i ^� ❑ Irrigation ❑ Noncommunit PWS ry
w I I I I e \�,` ❑ Test Well ❑ Dewatering Y O Remedial
\
i i i -r �/ZM,�a CASING Drive Shoe? ❑ Yes �QJo HOLE DIAM.
_i � _L_ _i_ � ❑ Steel ❑ Threaded ❑ Welded
' ' ' ' Q(Plastic CpC .'�ZLI�C�
s
�1 Mile�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME 9 in.to Z 75 ft. Ibs./ft. 8� i�,t�8 2 H.
St i ckne & Schwarz ��.to h. Ibs./it. in.to n.
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft.
��7 Manitoba AII�• cJ���srl SCREEN OPENHOLE
�7ayzata, MN 55391 Make Fv f�om tt.to n.
Type T�lescop TIC� Diam._
SIoUGauze � Length �
Setbetween 176 ft.and I8I fl. FITTINGS: R-Pac�er
STATIC WATER LEVEL
WELL OWNER'S NAME 2 fl0 ft. �6elow O above land surface Date measured 1����g6
Same PUMPING LEVEL(below land suAace)
Well owner's mailing address if different than property owner s address indicated above. ft. after hrs.pumping !�� g.p.m.
Sc�llle WELL HEAD COMPLETION
OCPitless adapter manufacturer 1"id�S Model
❑ Casing Protection C�{I2 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? �Yes ❑ No
HARDNESS OF Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete ❑ Hi h Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 9
from_�..tl to�ft. � ❑ yds. C�Lbags
from to R. ❑ yds. ❑ bags
�`��! .�30��. blaCk Q 2 from to ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
�1 a y Y�11 OW 2 z(.� feet direction type
Well disinfected upon completion? C�Yes � No
c2ay gray 29 94 PUMP 1OJ21146
❑ Not installed Da installed
- Manufacturer's name �te��^r �£
sand & t�. rk�v$1 yellow g� 1�4 Modelnumber HP � �i Vo¢�
�f1 Length of drop pipe �' f[. Capaciry 1 g.p.m.
B 1 a� g r a y 1 L 1 1�� Pressure Tank Capaciry
Type: q+Submersible ❑ L.S.Turbine ❑ Feciprocating ❑ Jet ❑
aan� yellow 1�46 181
ABANDONED WEILS
Does property have any not in use and not sealed well(s)? ❑ Yes LI No UL�kI����
VARIANCE
Was a variance granted from the MOH for this well? ❑ Yes �Jo
WELL CONTFACTOR CERTIFICATION
Use a second sheet,il needed This well was dritled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge.
�*Av�rc nri��ing �8�r�viron�zental 8665
Licensee Bus�ness Name Lic.or Reg.No.
Authonzed Representative Signature Date
Paul Swearinc�en 10/9/96
� !� Name ol Oriller Date
. . - .. :�1 �, �V
9.. �y
�",k E`� '.� '" � � HE-01205-05(Rev.1/95)
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