HomeMy WebLinkAboutwell info MINNESOTA UNIQUE WELL
WELL/BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County Name WELL AND BORING RECORD
Fieanepin Minnesota Statutes,Chapter 103I 7 4 2 7 4 9
� Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
" Urono I1$A 23�i 32 ,� Ri�t ,� SE,� 180 n Octaber 16� 2t306
GPS DRILLING METHOD
LOCATION: Latitude degrees minutes__ seconds__ _ _
'Cable Tool �.�rD.�r.ivIen► VC� �.Dug
Longitude__ degrees minutes seconds .-;Au er �pi�y�1 G �;.'Jetted
House Number,Street Name,City,and Zip Code of Well Location or Fire Number � , 9 �l�-
300 Stubbe B$� � �i QI0110 DRILLING FLUID W�L Y CTURED? L Yes No
Show exact location of well/boring in section grid with"X." Sketch map of well location. VSt2= \V,� From .To ft.
Showing property lines,
N roads,buildings, USE ZDomestic G Monitor(ji��qrr o '-Heating/Cooling
� and direction. '. I Noncommunity PWS �`'�n�on,.aS�re Hole .. ;Industry/Commercial
. I I Community PWS #Irrigation . .Remedial �
V' ( i. �Elevator ❑Dewatering f:��
' �' ' ' � � - CASWG MATEAIAL Drive Shoe? � �.Yes _- No HOLE DIAM.
:.. W ' , ' � E T _ ��Welded
: , ; , ; I . �.Steel ❑Threaded '�
--�--- --'--- -�-- --`- � ;.
' ; ' ; ' /z Mile � ..�--�
� �� �
�last c S 4&
' -:--- - �-- -.-- ------ 1 ,,,,� ,
,, �+�"""'^'�" CASING
� � y,#j Diameter Weight Specifications O1 L '
i �--'1Mile-� i ,K.(� _ R 175 -- Vi `�0 �
in.to ft. Ibs./ft. -tp-=�in.to�ft.
� in.to ft. Ibs./ft. "� in.to ft.
PROPERTY OWNER'S NAME/COMPANY NAME
in,to ft. Ibs./ft. in.to ft.
Hitkory FIne HQ�B� OPEN HOLE
SCREEN
Prqpq�ty{yvnexr's�a�liQg address if ditterent than well location address indicated above. Make_.`� eO From __ ft.To ft.
ri7 .DC/ 81.7 �t�
�OAg LSL.a� � .75.756 Type _ __ Diam.__.
Slot/Gauze_ i18C t Length_ _ �
- Set between L 7.,r ft.and a ft. FITTINGS � � p�C �r
� STATIC WATER LEVEL
,' 97__ft.�Below -.Above land surface Date measured 1�^1�'�0�
�. � PUMPING LEVEL(below land surface)
. WELUBORING OWNER'S NAME/COMPANY NAME
� Aickory Fine HO�B _ft.after hrs.pumping �O_ g,p.m.
;; WELL HEAD COMPLETION p "
} Well/boring owner's mailing address if different than property owner's address indicated above. ':_.pitless Adapter Manufacturer �8'BS Model �
� �O� R15 i J Casing Protection__ � _1$12 in.above grade
LOAg L8�@ i MN SS3Sv �.At-grade(Environmental Well and Boring ONLY) -
GROUTING INFORMATION
Well grouted? �Yes �-No
Grout materials , 'Neat cem nt '�Bentoni .Concrete ' :Oth
From_�_To �� ft. � ��Yds. �Bags
From To ft. I]Yds. 17 Bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To__ft. �_�Yds. I 1 Bags
MATERIAL
NEAREST KNOWN SOURCE OF CONTAMINATION�{�@r . 1'CC� SeiTet
C�.ay �eZ�OFl � 2d _ _feet __ direction type
Well disinfected upan completion? �Yes ��I No
CI.By grA�T 'Z� (� PUMP �
�4'� /5l��j�-'' —
J Not installed Date installed �
C18�1 �t gISV@'�. g18�1 Ve i�� Manufacturer's name_ 7 � r +�'�� V 11�� � '
J k
nA Model Number HP � /�Volts
Fj'raYe� flt sand gr83T 1uv �25 Lengthofdroppipe � � � R. Capacity ` `- ._ g.p.m.
Type::��6ubmersible G'LS.Turbine r I Reciprocating f�I Jet r
Cl.$y bt grflV@� red �25 ibs ABANDONED WELLS
Does property have any not in use and not sealed well(s)? '7 Yes pQNo
granel � SSIld �$y I�S i�o VARIANCE
Was a variance granted from the MDH for this well? . �.Yes �No TN#
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
� The intormation contained in this report is hue to the best of my knowledge.
Use a second sheet,il needed.
��� REMARKS,ELEVATION,SOURCE OF DATA,etc. SC@VeIIB Drilling � B�ii�iro�ntal Svc �IZSS
� -
Licensee Business Name � Lic.or Reg.No.
),\ �
;� �;.:y .. -� r _
Authorized Representative Signature Date
Randy Johnson
— — . --- —
7 4 2 7 4 g Name o�Driller
LOCAL COPY HE-01205-09(Rev.9/OS) f
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