HomeMy WebLinkAboutWater Well Record STATE OF MINNESOTA DEPARTMENT OF HEALTH
1.LOCATION OF WEP WATER WELL RECORD MINNESOTA UNIQUE WELL NO. A
County Name
47744
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Minnesota Statutes 156A.01.08 /or Wafer Sample
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Township Name r It ownsrop Number I Range Number SectIion No. Fraction 4.WELL DEPTH(completed) Date of Completion
E f _
/'rips / N IV
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Nutnei•tcal Street Address and City of Mll Location or Distance f Road Intersection. 5. DRILLING METHOD
J.—l. ElCableTool ❑Reverse ❑Driven 11 Dug
how exact location of well in section grid with"X." Sketch mj of well location. ❑Hollow Rod ❑Air ❑Bored ❑
N Addition Name may. ` ' /dyF` Atotary ❑Jetted ❑Power Auger
6.DRILLING FLUID
} 11+111
Block Number ' I 7.USE
h�
mes[ic flMonitoring ❑Heat Pump
' I,ot Number U Irrigation ❑Wublic ❑Industry
f-mi.
, ❑Test Well ❑Municipal ❑Commercial
--t- i- - -r- I ❑Air Conditioning ❑
t , 1
F--1 mile, 8.CASING I HOLE DIAM.
2.PROPERTY OWNER'S NAME Mailing Address if different than property address O Black ❑Threaded
E
tfEIGHT:Above/Below
indicated above. dace (t.
❑Galy. ❑Welded
Drive Shoe? Yes—No—
Mastic ❑
lbs./ft. -4n.
`_ ,�"„�:r�r"y✓� �in.to L�/ft. Weights '
3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to _ ' (t. Weight lbs./ft. }ten. tot. is
FORMATION
in.to ft. Weight lbs./ft. in. to t.
9.SCREEN Oropen hole
from ft.to. ft.
Make
e
Slot/Gauze s Length FIT INGS:
��� �r1/ Set between I rift.and�,j�ft.
10. STATIC WATER LEVEL /
I04
_ft.D below ❑above Dale Measured y
la urface
n
11. PUMPING LEVEL(below land surface)
ft.after hrs.pumping _ g.p.m.
ft.after hrs.pumping g.p.m.
12.HEAD WELL COMPLETION
gPitless adapter manufacturer-,tModel
'.❑Basement,offset ❑At least 12"above ground
❑Plastic casing protection
13.WELL GROUTED? ;$Yes� ❑No
Veal Cement ❑�Bentonite ❑
Grout material from to_ ft.cu.yds.
14. NEAREST SOURCES OF POSSIBLE CONTAM{)AATION
_C�Peet J direction g o type
Or
Well disinfected upon completion? JJQes ❑No
,y.
15. PUMP
Date installed Cl Not installed
Manufacturer's name
Model number number C 1 'i !w7/I HPZ_Volts-) O
Length of drop pipe U ft. Capacity g.p.m.
Material of drop pipe `^<
Type:9 Submersible ❑L.S.Turbine ❑Reciprocating
❑jet ❑Centrifugal ❑
16. ABANDONED WELLS
Unused well on property? ,JYes ❑No
Use a second,heel,'J--h d wed Permanent ❑ Temporary ❑ Not scaled
1 17.REMARKS,ELEVATION,SOURCIrF DATA,etc.
` 18.WATER WELL CONTRACTOR CERTIFICATION
This well was drilled under my jurisdiction and this report is true to the best of my
- knowledge and belief. -}
NOV Licensee Business Name ' License No.
2 5 2991 Address
Signed y• �. Ld�-"�- Date ! J 1 •y/
Authorized Representative
i
Date)
Name oJDriller
T477429 /7430M
77/76 30M
LOCAL COPYxE_o>Iios-os(xey.9/88) 7/7830M4
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