Loading...
HomeMy WebLinkAboutWell Record STATE OF MINNESOTA DEPARTMENT OF HEALTH ABANDONED WELL RECORD It. LOCATION OP til ll l MINNESOTA UNIQUE WELL NO. (leer. blank If not known) County Neee Hennepin Tiwioip lam' Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed N E b b of ti or ft. Orono 118N sr 23W w 31 SW NE NW 127 _5/10191 Numerical Street Address and City of Well location or Distance fro. Road S. DRILLING METHOD (If known) Intersection 10 Cable tool a[(N 70 Driven IC0 Dug 20 Hollow Noe SO Alr HD Bore 110 4545 Watertown Road x]Rotary 60 Jetted 90 Power Auger Show exact location of well (in section grid with '11 Sketch map of well location 6. ORSiNUCt10N5 N Well obstructed[] Yet [ No Obstructions removed 0 Yes 0 No If obstructions cannot be removed. contact MON s before sealing. W - • - ' - - • -I- E T 7. USE 1W Domestic {]Monitoring 80 Neat Loop • y .i. 10 Irrigation S(]Public 9Q Industry I[]Test Well Municipal 11x]Co.vnerclai 70 Air Conditioning 110 ►-1 �i V 7. PROPERTY OWNER'S NAME Mailing Address If different than N. CASINGIS) ^I property address indicated above ID Black 40 Threaded 1[] Earl Freeman P.O. Box 685 7[} Gale. sp Welded Lemont , IL 60439 7(]Plastic 60 Stainless Steel HARDNESS OF 2 tn. to ft. 1. FONMTION LOG COLOR FORMATION FROM TO ^ If not known, indicate formation log from new will or nearby well. in. to ft. 9. SCREEN lc]Screened well from ft. to ft. (If known) 0 Open Hol. from_ ft. to _ ft. 10. STATIC WATER LEVEL 85 ft. Cg below ❑above 5/10/91 land surface Dat. Measured II. WELLHEAD COMPLETION IC]Pities' Adapter Q Found buried AC] Basement offset sQ 734 Well Pit IS. REAINRS, ELEVATION. SOURCE OF DATA - CASINGS REMOVED. CASINGS PERFORATED, ETC. 12. GROUTING INFORMATION Y:Neat Cement 7[]bentonite x] Grout material3 hags from() to 12-ht. cu. yds.10 13. NEAREST SOURCES Of CONTAMINATION _ feet direction type Well disinfected before ruling? 0 Yes le. PUMP 0 Removed c4 Not Present Type: 10 Submersible x] L.S. Turbine (]Reciprocating 70 Jet 4E]Centrifugal Ix] IS. EXISTING WELLS (Please sketch locations of abandoned and active wells In remarks taction or On back.) Other unused well(s) on property? O Yes Cg No Abandoned: 0 Permanent C]Temporary (3 Not Sealed 17. WATER WELL CONTRACTORS CERTIFICATION This well wet sealed under my Jurisdiction and this report Is true to the best of my knowledge and belle!. Stevens Well Drilling Cn_ :'7194 ten tee Iwlnuf Na12me license No. 624 IIighway West Address Maple P • MN 55359 sired-jr /Jct.._.. oao5/10/91 Dias evens Date5/10/91 Name .f Driller .f►sort A/AlioONEo wit RECORD ins? M used for Property Transfer) TXPOtTAI', Pill VITT DRRD MINNESOTA UNIQUE WELL NO. WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH County Name WELL RECORD5 3© 2 Hennepin Minnesota Statutes Chapter 1031 8 Township Name Township No. • Range No. Sectjon No. Fraction WELL DEPTH(completed) Date Work Completed ft. Maple Plain 118N 24W 25 SW''SE''MW 137 5110/94 Numerical Street Address and City of ell Iron or Fir Number DRILLING METHOD iiiiilii lliXln" 4545 cv7 Pc( ❑0 Auger Cable Tool ,�0 Driven Rotary ❑ Dug ed Show exact location of well in section grid with"X". Sketch map of well location. 0 Showing property lines, N roads and buildings. DRILLING FLUID --ir- -1-- - Bentinite I i .USE 0 Heating/Cooling _ X Domestic ❑ Monitoring W i E ❑ Irrigation 0 Public ❑ Industry/Commercial T 0 Test Well 0 Dewatering ❑ Remedial I . I'"' CASING Drive Shoe? 0 Yes X No HOLE DIAM. --1- - - ---r- 1 0 Steel 0 Threaded 0 Welded X Plastic H----1.1,,-----, i /X glue CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME 4 in.to 130 ft. lbs./ft. 81/4 in.to 137t. Jeff Brol 1 in.to ft. lbs./ft. in.to_ft. Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. SCREEN -T_ayeG OPEN HOLE 1%5County Road 6 Make PVC from ft.to ft. Maple Plain, MN 55359 Type Diam._3. Slot/Gauze 18 Length 7 Set between 1 30 ft.and 137 ft. FITTINGS: STATIC WATER LEVEL GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TOft. below 0 above land surface Date measured 5/10/94 MATERIAL 102 PUMPING LEVEL(below land surface) Clay yettow 0 30 ft. after hrs.pumping 40-50 g.p.m. WELL HEAD COMPLETION Gravel yellow 30 48 0 Pitlessadaptermanufacturer Model 0 Casing Protection 0 12 in.above grade Clay/ gravel Gray 48 94 GROUTING INFORMATION Well grouted? X] Yes 0 No Clay Gray 94 107 Grout Material X Neat cement 0 Bentonite y from 6 to 30,X 8 0 yds. Ix bags from to ft. ❑ yds. ❑ bags Gravel/Sand Mixed 107 137 from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION feet direction type Well disinfected upon completion? 0 Yes 0 No PUMP 0 Not installed Date installed 6/29/94 Manufacturer's name Moyers <'.-` -.` Model number HP 1 Volts Length of drop pipe ® ft. Capacity 15 g.p.m. Pressure Tank Capacity 40 gal . Type: IX Submersible 0 L.S.Turbine 0 Reciprocating 0 Jet 0 ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes X No WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. C `'C The information contained in this report is true to the best of my knowledge. Use a second sheet,ifn EcE' EQ Stevens Drilling &Env., Inc. 86654 REMARKS,ELEVATION,SOURCE OF DAIAj,'efp. 1 Inn A Licensee Business Name Lic.or Reg.No. \R\F\f{u(� JJ`F .-c-k a 44415/94 GayOF ORONO Authorized Representative Signature Date Michael Stevens Name of Driller Date LOCAL COPY 5 3 0 2 8 7 HE-01205-04(Rev.5/92)