HomeMy WebLinkAboutWell/boring Construction Record _ MINNESOTA UNIQUE WELL
WELL OR BRING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County Name WELL AND BORING CONSTRUCTION RECORD
Hennepin Minnesota Statutes,Chapter 1031 [-826626
Township Name Township No. Range No. Section No. IFraction WELL BORING DEPTH(completed) DATE WORK COMPLETED
Orono 117 23 03T +l �
GPS LOCATION—decimal degrees(to four decimal places). DRILLING ME
Latitude Longitude ❑Cable Tool ❑Driven
❑Auger Rotary
House Number,Street Name,City,and ZIP Code of Well Location ❑Other
540 Willow DRS Orono 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes X11
Show exact location of well/boring in section gric with"X.' Sketch map of well/boring location. bentoriit@ From ft.To ft.
Showing property lines, ggEE
N rlCl roads,buildings,and direct. USE
tic ❑Monitoring ❑Heating/Cooling
i i______ 1 f� Rt711C6mmunity PWS ❑Environ.Bore Hole ❑Industry/Commercial
` Community PWS ❑Irrigation ❑Remedial
NOV0 2
4�for ❑Dewatering ❑
W E T CASING MATERIAL Drive Shoe? ❑Yes ,<No HOLE DIAM.
Threaded
MilWelded
CITY OF 0 Nb °T °W
'h e � °
Diamete
l
CASING
,�- CASI G Weight Specifications Q
I--1 Mile { k0?'p7 4 in.To 220 ft. Ibs./ft: v n.To 50 ft.
PROPERTY OWNER'S NAME/COMPANY NAME n.To ft. lbs./ft. in.T730 ft.
Nornp9p, Inc• in.To ft. lbs./ft. in.To ft.
Property owner's mailing address if different than well location address indicated above.
SCREEN OPEN HOLE
Make ism To ft.
700 Fast lalC@ St n213 O�TiFrom ft.
W f Y!' Type Stainless ess 4teal Diam.
tdayzat8, t+ j 55391 SloUGauze .010 Length 41 4 49
Set between ft.and ft. FITTING M
STATIC WATER LEVEL Measured from
ftOBelow ❑Above land surface Date measured
WELL OWNER'S NAME/COMPANY NAME PUIVIP1NG LEVEL(below land surface) f1
210 ft.after 2 hrs.pumping 50g.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �,�y,y yy�,,�
�.�
Pitless/adapter manufaci_6 Model
❑Casing protection 112 in.above grade
❑At-grade [:]Well House ❑Hand Pump /�
GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
MaterialhPnt(N1�From 0 To--50_ft. 3 ❑Yds. Bags
MaterialCUt_t ing From 50 To-220—ft. ❑Yds. ❑Bags
HARDNESS OF Material From To ft. [-]Yds. ❑Bags
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags
NEAREST KNOWN SOURCE OF CONTAMINATION
C18 /sand brown Toedium 0 31 99 feet 1A direction �l���_type
clay/sand &ray nedium 31 Well disinfected upon completion? es E]No 4
"'ravel sand mix im 68 77 PUMP nf
fine sand brown !;Oft77 150 E]Not installed Date installed 8—`"—27
gravel/clay brown Tedil= 1150 1r)3 Manufacturer's name G?�e. nfnr
clay red um ��3 lq Model Number ; HPfl-5Volts230
clay ,,ray ium 184 204 Length of drop pipe 105 ft. Capacity g.p.m
sand/gravel tan 1 ,iun 2. + 10
dine sand brown ( <jT'1 ?1'.J 21el Type Submersible E]L.S.Turbine [j Reciprocating ❑Jet ❑
ABANDONED WELLS
gravel/saner yellow nedium 219 1303
Does property have any not in use and not sealed well(s)? ❑Yes No
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes>e No TN#
WELL CONTRACTOR CERTIFICATION
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.
REMARKS,ELEVATION,SOURCE OF DATA,etc.
Don Stodola Well DrillirkS Co, Inc. 1691
Licensee Business Name Lic.or Reg.No.
9-1£-17
Certified Representative Signature Certified Rep.No. Date
LOCAL COPY �826626 Name of Driller Roti Stodole
ID#52603 HE-01205-15(Rev.8/13)