HomeMy WebLinkAboutWell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH M/NNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 6 4 8 5 7 2
,���,�� � Minnesota Statutes Chapter 103/
Township Name Tovmship No. Range No. Sectfon No. FracNon WELL DEPTH(completed) Date Work Completed
f�rs�s.�o lI7 23 1C! �a�,�.�Ei. S�' ,�. � 1:�7 � 9f 14/I�tU
House Number,Street Name.Ciry,end Zip Code of Well Location or Fire Number DRILLING METHOD
i?SO Axbo� S�r��t C s��l �3� ❑ CableTool ❑ Driven ❑ Dug
s � � ❑Auger �I Rotary ❑Jetted
Show exact locatlon of well in section grid with°X°. Sketch map of well location. ❑
Showing property tlnes,
roads and bwldings. DRILLING FLUID WELL HYDROFRACTURED7 ❑YES I�NO
N ,t� (".�
i i i ,'� 4�;1,++.,. - W$�CT FHOM (t.to ft.
-i -�- -i- -i
USE ❑ Monitoring ❑ Heating/Cooling
� � � � � f6 Domestic ❑ Community PWS ❑ IndusVy/Commercial
-�- -�- -�- -�- r O Irtigatlon
1,�'�'. � ❑ Noncommunily PWS ❑ Remedlal
yy � � � � E Y� ❑ Environ.Bare Hale ❑ Dewatering ❑
� � � , T �,f�w
i i i i ��� CASING Drive Shoe1 ❑Yes �No HOLE DIAM.
i- -�- -i- -i- ❑ Steel ❑Thread� ❑Welded
S
1 � �.�d�_..,� .�P��� � ����
���� CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME +�! in,to �g� tt. IbsJR. �� in.to�SA tt.
�"n �. Fc71'��.@ In.to ft. IbsJfL �In.to�>�R
Properry owners mailing address ff different than well location address indicated above. in.to ft. � Ibs./tt. _�,to_ft.
125t� Aiccbor S'Cr�Lt SCREEN OPEN HOLE
Gr�st�l �a.y, '�i 55323 M�8 �a��a from n►a rc.
Type g�t+ Diam. �tt
SIoVGauze_i.�' Length ��
Set between �7�_ft.and�_ft. FITTINGS: ����,C�{@p'
STATIC WATER LEVEL }
WELL OWNER'S NAME � ft.�below �above land surtace Date measured�/1 I_�___�____^f�`I�
PUMPING LEVEL(below land suAace)
Well ownePs mailing address fl different than property ovmer's address indicated above. (t. after hrs.pumping �Q a.p.m.
WELL HEAD COMPLETION
W�Pl�ess adapter manufacturer �9ntr�_Model �f�
❑ Casing Protection �Q,12 In.above grade
❑At-grade(Environmental Wetls and Borings ONLI�
GROUTING INFORMATION
Wetl groutedl �,Yes ❑ No
HARDNESS OF Grout Material ❑ Neat ceme BentonRe ❑ Concrete ❑ Hi h Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �m �j �`to (�S n. � ❑ yds. 6� bags
from to ft. ❑ yds. ❑ bags
�'la�i ���-�� � �5 from to ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
(�'i$!7 �i'ra�'g �� �.�j� feet direction �type _
Well disinfected upon completion? �Yes ❑ No
GTr^SV�E'�/G�.'�.�,� G'gc4� �.VQ 17�D PUMP
❑ Notinstalled Datemstalled �1�E}���
��'���1' ���� �'�� �'97 ManufactureYs name ��tT7PrB
Modal number HP Volts
Length of drop pipe $� ft. Capaciry =2 a.p.m.
Type: Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)T ❑Yes �No
VARIANCE
Was a variance granted from the MDH for[his well? ❑ Yes No TN#
4
WELL CONTRACTOR CERTIFICATION
Use a second sheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF DATA,etc. The Intormation contained in this report is true to the best of my knowledge.
Stteven:� DriZiin� & Env. Se�rice�, I�.e. 86654
� Ucensee Busll�ess Name Lic.or Reg.No.
� #� -� s, ��'ti, i4y ,'�m�3������
t �=t;
Authorized RepieSentative Signatu e ' Date
I�3i2la�' �Q��S+9L3 ����Fd�� �
6 4 8 5 7 2 Name o/Dnller Date
LOCAL COPY HE-01205-07(Rev.2/99)
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