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Home My WebLink Aboutwell info . .,...��. .. .. . : , , ,... . ,. , . . ,w,�,,,,,..,..,.. WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AEND BORINIQ NOWELL �o �YName WELL AND BORING RECORD 7 c� 2� 6 6 Minnesota Statutes,Chapter 103/ � Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED �r ' n� a� �� N� 13C� ,� N � a�� p GPS DRILLING METHOD LOCATION: Latitude degrees _ minutes seconds ._ Longitude degrees minutes seconds ��]Cable Tool I ��Driven Dug --- Y�Auger �!Rotary ',]Jetted House Number,Street Name,City,and Zip Code of Well Locatiory_,� or Fire Number - - �� y �� ,r��. A �� /)r�7J DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No i/ Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. ��_��f` From ft.To ft. Showing property lines, — roads,buildings,and direction. USE � N �Domestic _Monitoring ��j Heating/Cooling __j_____j___ __;__ _ !__ - . ,. ',Noncommunity PWS � )Environ.Bore Hole � �Industry/Commercial �]Community PWS L Irrigation _.��;Remedial --�-----;--- --�-- ---�-- '�I Elevator ❑Dewatering [� w ; ; ; ; E� CASING MATERIAL Drive Shoe? '��Yes �No HOLE DIAM. c� --'--- --'------�-----'-- � . !�Steel ':_',�Threaded �L_�.Welded , , , , '/Mile "_'�-'..^"^"`.,,�.....- "` , , , , �� Plastic ' --,--- --,-- ---�-- ---�-- i U. � �� ; ; � � CASING S � � � Diameter Weight Specifications ` }� �1 Mile—� I'f%"�1�.�j ._"j_ ___in.to. '�� ft Ibs./ft. �/�in.to�v ft. f PR TY OWNER'S NAM iCOMPANY NAME in.to ft. Ibs./ft. in.t�t. �y in.to ft. Ibs./ft. in.to ft. � (�4V�� .��V� Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE ��[ K //'��, � . Make From ft. To ft. G%�.J l�f��•1��✓ � TYPe -1F-� _ Diam. y + . � � �� Slot/Gauze -�t � / Length {� �� G.�� `�'� �� -�'' �"l Set between. �" ft.and__��c�ft. FITTINGS t�l �!�':-�'.r STATIC WATER LEVEL Measured from �* --�... ��_,. ft.� Below [J Above land surface Date measured_�L__.�. �j(� W, OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �� { ,(. �"E � (_�( �i..'� ft.after__ hrs.pumping�(,� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION // Pitless/adapter manufacturer__ ��'� Model j_Casing Protection_ _ __ _ _12 in.above grade At-grade(Environmental Well and Boring ONLY) GROUT G INFORMQ.TION Wel�r�e� es � �No� �� ( Grout matenalsi��_. eat cement ,_;Bentonite . �Concrete ',�'Oth� _ i'� ___ From To_. _fl. �.__Yds. ,J Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft ��,_�Yds. (�Bags MATERIAL From To R. �._Yds. �,�Bags � � � NEAREST KNOWN SOURCE OF CONTAMINATION��/?� ijrri �(,,l,J�{:, � � � G'�L�`�-"� � � �� feet direction type � ��` Well disinfected upon completion? �Yes [J No �.��1.� "^� PUMP �� j 'Not installed Date ins Iled /� �I� �� Manufacturer's name � �'}'� I� Model Number HP Volts �-t �C� '% / J Length of drop pipe_._�__ R. Capaciry ��_g.p.m. Type:��. Submersible LS.Turbine ❑Reciprocating �,�Jet �] ABANDONED WELLS 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? ;J Yes No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The inbrmation contained in this report is true ro the best of my knowledge. � Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. t ( � ,,,,,,,, J�-Pv.'n� �v-1�i�i� �4 �l`1 v �....alL o�a �'� ' ensee Business Name Lic.or Reg.No. --""'�`�"��a�, /if,. �._,_... ¢��J Cer i ied Representative Signat e Certified Rep.No. Date L�CAL COPY 7 �2 E � E Name of Dri ler Y' t,/ �U�n�� ' IC 140-0020 HE-01205-12(Rev.12/08) � WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' /�Q�(`1 � W E L L A N D B O R I N G S E A L I N G R E C O R D Minn1egoNa Unique Well No. G!� ci �, Count Name or W-series No. Minnesota Statutes,Chapter 1031 ��ae�a e,a�k,�o,k�ow�� ✓l,�1.� i �(�1 To ship Name ownship No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed �17� v� '7 SGt�hl� ' I�UV. �, �C� J v GPS Latitude degrees minutes seconds Depth Before Sealing 7� ft. Original Depth_ ft. LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of ell or Boring Location � Single Aquifer ❑Multiaquifer ) v1 WElLI80RING �'Measured ❑Estimated Date Measured � � 4r�� ! � ��f' � `�Water-Supply Well �]Monit Well Show exact location of well or boring Sketch map of well or boring � j� in section grid with"X." location,showing property �,Env.Bore Hole []Other V�ft. �below ❑above land surface N lines,roads,and buildings. CASWG TYPE(S) . . --'--- --'------`-- --'— �, �Steel f.�Plastic L]Tile ❑Other --�--- --�---'--`-----`-- WELLHEAD COMPLETION W : : : : ET � � � � Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset 'h M�ie �Pitless AdaptedUnit ❑Buried ❑Well Pit ; ; ; ; 1 ------ ------ ---�-----:- - ❑Buried ' ' S ' ' ❑Well Pit ❑Other f--1 Mile� r�}� �Other P TY OWNER'S NAM /COMPA Y NAM CASING(S) � � Diam er Depth Set in oversize hole? Annular space initially grouted? Prope ner's mailing ad i ditterent than well Iqcation address indicated above �in.from_�_ t0�ft. �Yes ❑No �Yes ❑No ❑Unknown 1 a��5 �2��-r I�� . �N � S 3� � in.from ro R ��Yes ❑No ❑Yes ❑No ❑Unknown W�-��. in.from ro ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WNER'S NAME/CO ANY NAME SCREEN/OPEN HO� /� �C� 1 �2 ` (�'�ry Well owner's mailing address if diflerent ihan property owner's address indicated above Screen from � to f O fl. Open Hole from to ft. OBSTRUCTIONS �RodslDrop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction Type of Obstructions(Describe) Y/�G �{ a^_1-�__ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? � Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. t^ TYPe�[�� Removed ❑Not Present ❑Other METHOD USED TO SEAL ANNULAH SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) ; Grouting Material ��/J� / Of��l� �from_�. to�[� ft. yards� bags from to fl. yards bags from to R. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? '`I Yes No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This weil or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. ; � )Y � [ !1 . SVG • ��a4.�� Licensee Business ame License or Registration No. Jt``a� ��;�c�' 1� � Certilied Rep�esentative Signat e Certilied Rep.No. Date ..,....w"�'� � �oer:,_coPv H Z��61 s �+1M .,,�[�"V P y1 S — — Name of Person Sealing Well or Boring . HE-01434-12 IC#140-0423 siosR