HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
- County Name WELL AND BORING RECORD 5 7 2 7�. 7
j-j��yl�a�j,� Minnesota Statutes Chapter 103/
Township Name Township No. Range No. Section No. Fraction WE�L DEPTH(completed) Date Work Completed
Orono 327 23 4 NW .SW SI� 1.51 n l�/�Y/9b
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHUD
°�7� S�11:3 c..�LX (�'"1 r�1@ ❑ Cable Tool ❑ Driven ❑ Dug
❑ Auger C�}.Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑ _
Showing property lines, T
'`�� roads and buildings. DRILLING FLUID
" � �Cj w�d t::T'
_� � � �_ �
,- -;- -,-- -, r
I I I `; USE ❑ Monitoring ❑ Heating/Cooling
�Domestic ❑ Communi PWS
-�- -a- -�- -�- ❑ Irrigation �' O Industry/Commercial
i i i i ❑ Noncommunity PWS ❑ Remedial
�,..._
w e� i ❑ Test Well
i � i i ❑ Dewatering ❑
i , i -r ,/2M.�a � CASING Drive Shoe? ❑ Yes C�No HOLE DIAM.
_i i _L_ _i_ � ❑ Steel ❑ Threaded ❑ Welded
i -i- i i
E�Plastic ❑
s
F---1 Mile-�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME � in.ro 1'�7 R. Ibs./ft. � in.to "i�n.
A & 'i` DeV�1Cl�lIl�Zlt In.to__n. �bs.m. �in.td`iLn.
Property owner's mailing address if different than well location address indicated above. in.to_ ft. IbsJft. in.to ft.
SCREE OPEN HOLE
Make aY�� from ft.to ft.
Type �V� Diam.
SbUGauze � Length 7�
set between i 47 ft.and 1�J Z ft. FITTINGS: � �dCk+�1"
STATIC WATER LEVEL
WELL OWNER'S NAME a 1 fl.�] below ❑ above land surface Date measured
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. �� ft. after � hrs.pumping 5� g.p.m.
WELL HEAD COMPLETION
L�Pitless adapter manufacturer w h i t e��a te r Model .��r'3�t3
❑ Casing Protection ❑ 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONIY)
GROUTING INFORMATION
_ Well grouted? �l Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement C�Bentonite ❑ Concrete ❑ High Solids Bentonite
MATERIAL from �5 to � ft. ❑ yds. ❑ bags
clay p,rQ�jpl ��(;(� � c�jj from to ft. ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
IQ�CI• NEAREST KNOWN SOUFiCE OF CONTAMINATION
�:iay j31Ut: ��z.d �� ,�� =7� feet . ���+�r� direction `���t''r type
Well disinfected upon completion? �1 Yes ❑ No r
�and � yravel �ix m�ct. 49 bl PUMP 12/"l/96
c 1 a y �71 UL ��q� �1 b� � Not installed Date instal�ed
Manufacturer's name � —
ModelnumberlUP�F02JJ— HP 1 vonsr���
�t�11C� �c `.�rdV-t��'Z TR1X SU��i �rJ' 1�� Lengthofdroppipe r �� i��ap�city_ 2►� g.p.m.
Pressure Tank Capacity �r
s a nd y i:.1 3 Y �.}�.I3 e'�' S O f� L I�J 1 2 7 Type:�] Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
5 d��� .fJ�GT(f1 C�ii�:.,�• 1�� 1 rJ� Does property have any not in use and not sealed well(s)? ❑ Yes {9 No
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,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge.
H.E.S. 4��11 Brilli�i; i7i7�
Licensee Business Name Lic.or Reg.No.
� �_ , �-�..�"'r`-.�:a� ,: �� ,l �G�
Authorized Representative Signature Date
Kot��rt E. Stodc�la, �r. llj3l��
Name o/Driller HE 01205-OS(Rev.1/95)
LOCALCOPY j ?�7 ��