HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELLRECORD 3 5 6 2 2
tI F�V U,, Minnesota Statutes Chapter 1031
Township Name Township No. - Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
1 yi ! S V
Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Dug
C v.i.-pry C 1Vr S ❑ Auger Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
N roads and buildings. DRILLING FLUID
.
i 1 rk USE ❑ Heating/Cooling
PQ Domestic ❑ Monitoring
W i I E / ❑ Irrigation ❑ Public ❑ Industry/Commercial
�� ElTest Well E-) Dewatering O Remedial
-1- -1- T
F' "' d CASING Drive Shoe? ❑ Yes 151 No HOLE DAM.
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El Steel [I Threaded El Welded
1 �+v Plastic ❑
Vj`�`
1 milr r
CASING DIAMETER WEIGHT !
PROPERTY OWNER'S NAME t in.to J —ft. lbs./ft. !? in.tX ft.
n.to ft. lbs./ft. -7 in.tot 44 ft.
Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft.
SCREEN OPEN HOLE
Make �c�^' .•"' from ft.to ft.
jType 'r+, Diam.
1 r r 0 Slot/Gauze Length 'l1 r
Set between ft.and_. H 4-- _ft. FITTINGS: �
6
STATIC WATER LEVEL
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TOi_ c!3
MATERIAL ! ft. (below ❑ above land surface Date measured r
` \ PUMPING LEVEL(below land surface)
ft. after
hrs.pumping �� ) g.p.m.
tt WELL HEAD COMPLETION t{ SS /
1 `� c, .! �J�'• M X Pitless adapter manufacturer W�^ k. Q1Z f e— Model
1 ❑ Casing Protection RSL 12 in.above grade
r
GROUTING INFORMATION
Well grouted? Yes ❑ No
Grout Material ? Neat cement 04 Bentonite
from to Zil- ft. 'K yds. ❑ bags
from to ft. ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMIN{ATION
t-� feet Nri direction •� `}� type
Well disinfected upon completion? r,Yes ❑ No ( .
PUMP
❑ Not installed Date installed e 1
RECEIVERECEIVEP Manufacturer's name
Model number HP 14y- Volts c 31
APR 2 2 1994 Length of drop pipe ft. Capacity t J g.p.m.
Pressure Tank Capacity U a 1r°?11 X
Cffy OF ORON0 Type: 0 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes A<No
WELL CONTRACTOR CERTIFICATION
r,a+
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge./
Use a second sheet,if needed a.1 .k(CC- �7 a./14
REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. 4
A orized Representative Signature Date
07-In
Name of Driller Date
LOCAL COPi 15356221 HE-01205-04(Rev.5f92)