HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELL AND BORING RECORD615220
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Minnesota Statutes Chapter 1031 E'9 i 9 1999
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) ateiNvrkCompleted
G1TY Ur ��Dt iN
Drano 118 l3 33 Sir• SW sh 81 5/-1/fiIIIII9
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Dug
40 Truffula fraiti Orcitin ❑ Auger I[Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? C1YES ❑NO
- N -
. ' .9 FROM ft.to ft.
USE ❑ Monitoring ❑ Heating/Cooling
iiDomestic El CommunityPWS
❑ Industry/Commercial
_ _ i_ __ rigation
I
❑ Noncommunity PWS ❑ Remedial
W 1 ET El Test Well ❑ Dewatering C3i ,/zlM,ie CASING Drive Shoe? El El No HOLE DIAM.
i i > ❑ Steel ❑ Threaded ❑ Welded
XPlastic ❑
S
We
-- - CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME 4 in.to 76 ft. 2[1f11bs./ft.
�in.to_jj+ft.
j _� _T Dev2lopmentt in.to ft. lbs./ft. in.to ft.
Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to ft.
SCREEN OPEN HOLE
575 Sussex Circle Make fromPVC ft.to ft.
Orono, MN 55356 Type Diam.
Sen_? Length
Setet between ft.and ft. FITTINGS:
STATIC WATER LEVEL
WELL OWNER'S NAME [z 1 ft. CjLbelow ❑ above land surface Date measured
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. 4 4 ft. after hrs.pumping4.(�g.p.m.
WELL HEAD COMPLETION
EkPiless adapter manufacturer Model
❑ Casing Protection ❑ 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? [JLYes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete X High Solids Bentonite
MATERIAL from to 7 ft. j ❑ yds. wags
from to ft. ❑ yds. ❑ bags
Clair Drown read. 0 42 from to ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
clay iAUe IIled• 42 48 L 7 feet Qr t€r direction a is W �-r---Ptlrp
Well disinfected upon completion? ❑ Yes ❑ No
PUMP
❑ Not installed Date installed
Manufacturer's name bi�2.L, rs
Model number l HP l Volts ��
Length of drop pipe 60 ft. Capacity j;_g.p.m.
Type: ESubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes Eao
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes ❑kto
WELL CONTRACTOR CERTIFICATION
Use a second sheet,it 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.
RES Well Drilling 27276
Licensee�ess Name Lic.or Reg.No.
00
Authorized Representative Signature Date
Robtart _ stoei la, Jr. 5/7/x_
Name o/Driller Date
LOCAL COPY 1615220 HE-01205-06(Rev.9/97)