HomeMy WebLinkAboutwell info r-�, __ �'-1
WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH
MINNESOTA UNIQUE WELL NO.
County Name WELL AND BORING RECORD �g 4 9� 3
�je�lllepi,jl Minnesota Statutes Chapter 1031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
Orono 11� 23 08 ,. ,. ,, 107 JAN n� 24/97
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
1230 Sprnce Place �� cabie T°°i ��—^ ❑ ��„e� ❑ 0�9
f7 Auger �Rotary ❑ Jetted
� Show exact bcation of well in section grid with"X". Sketch map of well location. I 1
Showing property 6nes, --
� roads and buildings. DRILLWG FLUID
N Wstel
_� � � �_ �-� � t,U�.l I
,- -,- -r- -,
USE ❑ Monitoring ❑ Heating/Cooling
i i i i �Domestic
_�_ _�_ _�_ _�_ ❑ Community PWS ❑ Intlustry/Commercial
i i � � ❑ Irngation ❑ Noncommuniry PWS ❑ Remedial
W E ❑ Test Well
i i i i T C7 Dewatering ❑
_r _�_ _r_ 'r I �,,,,��.
� i i i ��zM�e CASING Drive ShoC? ❑ Yes (�No HOLE DIAM.
_i_ _i_ _L_ _i_ ❑ Steel ❑ Threaded ❑ Welded �
i i i i t
_„ 1 � �Plastic a ���___ . __
S
E---I M�le-�
CASING DIAMETER WE�GHT
PROPERTY OWNER'S NAME ___4 in.to 1�Z _ft. ___ _ Ibs./n. $ in.t�07 tt.
� $tt b NanC HQe � in.to__fl. Ibs./ft. in.to ft.
Property owner's mailing address if diflerent than well Iceation address indicated above. _—.— .in.to _ft. Ibs./ft. in.to tt.
10 �Tinnetka Av�. S• SCREEN_ p�C _ OPEN HOLE
Gol�en Yallep, MN 55426 "'ake ��1-' from h�o tt.
Type_Te1�BCOp AQ _oiam.
SIoVGauze_ � Length g _
Set between� � ft.an—d I���—__n. FiTrw�s:_K-Packer
STATIC WATER LEVEL
WELL OWNER'S NAME 4,� ft. �elow ❑ above land surtace Date measured 1 1 Z4 7
PUMPING LEVEL(below land surface)
Well owner's mailing address if ditterent than property owner's address indicated above. ,_ fl. afler_ ___ hrs.pumping 1�Q __g.p.m.
WELL HEAD COMPLETION
❑ Pitless adapter manufacWrer ___ Model .
❑ Casing Protection ___ ____ ❑ 12 In.above grade
❑ Abgrade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? � Ves � No
HARDNESS OF Grout Material � Neat cement � eM i�� rl Concrete ❑ Hi h Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
from � �_�ft. � ❑ yds.�bags
from__to R. ❑ yds. ❑ bags
Cli�j� j/l110Y 0 33 r�om _ co n. ❑ vas. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
Cli� Qr�� 33 4Z _ feet __,_ direction rype
Well disinfected upon completion? i.-1 Yes ❑ No
SBAY St QraVe btOYII 41 lO7 PUMP ♦
❑ Not installed Date instanee _ i�L�g���
Manufadurer's name �t^�_ _
Model number_ HP�_`_�__ Volts
Length of drop pipe �� ft. Capacity �� g.p.m.
Pressure 7ank Capaciry____�/ .p._ _
Type: ❑ Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes ❑ No nnknoxn
VARIANCE
Was a variance granted from the MDH for this well? �7 Yes ❑ No
WELL CONTRACTOR CERTIFICATION
Use a second sheeG i/needed This well was drilled under my supervision and in accordance with Minnesota Fules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge.
Stevens Drilling � Eavironmental 8�
� _ Licensee Business Name Lic.or Reg.No.
; : 12/16/97
Authonzed Representative Signature Date
Panl Sxearinqen
5 9 4 9 0 3 Name ol Driller Date
LOCAL COPY HE-01205-05(Rev.1/95)