HomeMy WebLinkAboutwell info STATE OF MINNESOTA DEPARTMENT OF HEALTH
1.LOCATION OF WEM WATER WELL RECORD MINNESOTA UNIQUE WELL NO. -15 )i,..
County Name for Water Sample 1 . �,_ 7
( Minnesola Statutes 156A.01..08
Township Name I Township Number I Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion
/ (t.
or or
S W1
Distance and Direction from Road Intersection or Street Address and City of Well Location 5, DRILLING METHOD
10 Cable tool 40 Reverse 70 Driven 100 Dug
Show exact location of well in section grid with-X." S¢elch map of well location. 20 Hollow rod 50 Air 80 Bored 110
N
Addition Name ^� 31!�Rotary 60jetted 90 Power gauger
6.DRILLING FLUID
_..
Block Number 7. USE
W E
ODomestcc 40 Monitoring 80 Heat Pump
I i
f-miLot Number 20 Irrigation 50 Public 90 Industry
. IN
30 Test Well fi❑Municipal 100 Commercial
70 Air Conditioning 110
1 mile 8.CASING HOLE DIAM.
2.PROPERTY OWNER'S NAME HEIGHT:Above/Below
1[I Black 40 Threaded
Surface 7 ft.
20 Galy. 50 Welded
� Drive Shoe' Yes— No-
Address 1/79� /v 30 Plastic 60
in.to - ft. Weight lbs./ft. in. to t.
3. FORMATION LOG COLOR HARDNESS OF FROM TO
FORMATION in.to ft. Weight lbs./ft. in. to_�t.
-
in.to ft. Weight lbs./ft. in. tort.
9.SCREEN Or open hole
from ft.to. ft.
Make
Type Dis.
Slot/Gauze Length FITTINGS:
Set between i - ft.and - ft.
10.STATIC WATER LEVEL
f ,
ft.O below ❑above Date Measured I
land surface
11. PUMPING LEVEL(below land surface)
_ ft.after hrs.pumping 9-P in.
ft.after hrs.pumping- 9-P in
12.HEAD WELL COMPLETION
10 Pitless adapter,manufacturer 'c � _model
20 Basement offset 30 At least 12"above ground
40 Plastic casing protection
13.WELL GROUTED?
0Y es ❑No
113Neat Cement 20 Bentonite 30
Grout material from to ft.cu.yds.
J
J14. NEAREST SOURCES OF POSSIBLE CONTAMINATION
feet direction type
Well disinfected upon completion? EINes ❑No
15, PUMP
Date installed _ ❑Not installed
Manufacturer's name
Model number HP Volts
Length of drop pipe ft. capacity 9-P in
Material of drop pipe
_ Type:1&Submersible 30 L.S.Turbine 50 Reciprocating
20 Yet 411 Centrifugal 60
16. EXISTING WELLS
Unused well on property? ❑Yes H'Sl.
Use a second sheet,if needed
z Abandoned ❑ Permanent❑ Temporary❑ Not sealed
+•`>-'"��' 17. REMARKS,ELEVATION,SOURCE OF DATA,etc.
18.WATER WELL CONTRACTORS CERTIFICATION
This well was drilled under my jurisdiction and this report is true to the best of my
knowledge and belief.
Licensee Business Name License No.
Address
Signed Date
- Authorized Representative
Date
Name of Driller
<-, 5/74 30M
LOCAL COPY 1-45 -
iiia 3aM
HE-01205-02(Rev.10/85) 2/82 IOM