HomeMy WebLinkAboutwell info r' �_'�""---A NESOTA UNIQUE WELL NO.
WELL LOCA ION MINNESOTA DEPARTMENT OF HEAL� C17Y r;F
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CounryName WELL AND BORING REC�FtD . ��
H r • � Minnesota Statutes Chapter f03/ �� % ! 5 915 0 4
Township Na Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Com�leted
arono 117 `l:, 4 'W riik S�i i 38 " :,/8/9 /
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House Ntu1mbe,Street Name,Ciry,and Zip Code ot Well Location or Fire Number DRILLING METHOD
319V jxSSeX �(��(j C7 CableTool Iy���� priv� ❑ Dug
f7 Auger j{7 �pta 1��� ❑ Jetted
Show exact lo tion of well in section grid with"X". � � Sketch map of well location. �1 ._ ��i�i _ _
�) Showing property lines,
� roads and buildings. DfiILLING FLUID
" water
� � � �
-� - �- '�' -�- �,,..._..---' USE ❑ Monitoring ❑ Heating/Cooling
i i i i I }Q Domestic ❑ Communit PWS �
'I Y ❑ Indust /Commercial
-'- - - -�- -'- �V ❑ Irrigation ry
i i i i � ❑ Noncommuni�y PWS ❑ Remedial
w e T � � ❑ Test Well
i i i i - ❑ Dewatering n
� i r ,�2IM�a CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
_i_ _ _L_ _i_ � ❑ Steel ❑ Threaded ❑ Welded
i - i i
ZC] Plastic ❑
s
i Miie-�
CASING DIAMETER WEIGHT
PROPERTY WNER'S NAME � in.to 131 tt. L0� �bs./ft.
-3�n�o b b n.
. A & �' Devr�lopment in.to ft. _ Ibs./ft. 4 in.t�4 ft.
Property owner mailing address if diHerent ihan well Ixation address indicated above. in.to ft. __ Ibs./tt. in.to__ft.
�J /S S fiS�C CZ.rCl� SCREEN OPENHOLE
Orono, �N 55355 Make Jayco from ft.to ft.
Type_ �V C. Diam.
SIoUGauze 1 2 .Length � �
Set between ],_,�_.1_fl.and�ft. FITTtNGS: -
STATIC WATER LEVEL
WELL OWN 'S NAME �C] ft.�below ❑ above land surtace Date measured
PUMPING LEVEL(below land surface) � �
Well owner's m iling address if diflerent than property owner's address indicated above. ��] R. after 3 hrs.pumping_�� g.p.m.
$�•� WELL HEAD COMPLETION � �-� �
�� ,�[7 Pitless adapter manufacturer W h i�e w a t e r M�e��J����
❑ Casing Protection ❑ 12 in.above qrade
❑ At-gratle(Environmental Wells and Borin gs ONLV)
GROUTING INFORMATION
Well grouted? :�i� Yes ❑ No
GEOLOGI AL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement �1 eentoni�e ❑ Concrete ❑ High Solids eentonite
MATERIAL from._�j_�to�ft. _�_ ❑ yds.JO bags
.,. tUt1 S �1 black lTl��l• Q � irom to fl. ❑ yds. ❑ bags
from to fl. ❑ yds. ❑ bags
�� NEAREST KNOWN SOUFCE OF CONTAMINATION
�Zc�ll l:rown iQECi. � Y7 �� feet 7w directionS�YT@1 �31�e
Well disinfected upon completion? v Yes ❑ No
�la� �111� meQ• 17 6� PUMP �I1 ZI gT
❑ Not installed Date installed
sanct & yravel bi'Oii12 1Ii2C�. 6� 1�1 Manutacturer'sname __ S�.d—RYt@ ����
� Model number S 1��� HP�Volts �'`�V
Length of drop pipe_ t� ft. Capacity �0 g.p.m. �r
Pressure Tank Capacity z 5 v
Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes �No
VARIANCE
Was a vanance 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,E EVATION,SOURCE OF DATA,etC. The information contained in this repoA is true to the best of my knowledge.
R.E.S. �ell DrillirY� 27276
���� Licensee Busin s Name^, Lic.oi Reg.N .
�':����--�.�'� � /3 ; �
' Authorized Representative Signature Date
ko�ert E. S�odc�la, 3r. 5/13/5?
Name ol Oriller Dafe
�ocA�coPv 5 915 0 4 ME-01205-OS(Rev.1/95)