HomeMy WebLinkAboutWell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CounryName WELL RECORD � $� 7 8 �
Hennepin Minnesota Statutes Chapter 1031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion
n.
��. ��, ��. 4 6 2 2
Numerical Street Address or Fire Number and City of Well Location DRILLING METHOD
f� �t1T I Cable Tool Driven � Dug �
�'+tJ varrett ��r�nue. Wa Za� 1'3i1• i.; Auger �.� Rotary .-�: Jetted
Show exact location of well in section grid with"X"./t� _! Sketch map of well location. ..�
l,J r�f'�� Showing property lines,
N roads and buildings. DRILLING FLUID
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_'r_ �_ _1 -1_ �3@13tt7li.t��>
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i i i , USE
W i � � E �!�' �I Domestic - Monitoring `� Heating/Cooling
� [' Irrigation � Public � Industry/Commercial
-�- -i- -; =- T � �.�� t� �;� C Test Well � Dewatering l
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f"m' CASING Drive Shoe? r Yes �'No HOLE DIAM.
'-�- �- - -r" � ❑ Steel LJ Threaded f 7 Welded
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1----I»+i1e,—� L E.'` � Plastic ❑
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CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME l�in.to_1�ft. I�g ibs.in. �33�;�,ro����g�' tt.
� I, ,� a in.to ft. Ibs./ft. ��►,tqt<xr ft.
Mailing address if different than property address indicated above. in.to ft. Ibs.ttt. in.to ft.
SCREEN OPEN HOLE
54�3 Barreti Avenue Make ,Tc1�1it�30ri trom�ft.to tt.
Type stainles� �i�.�L�. Diam.
W$�zata� ?+�N 55391 SIoVGauze 2tl Length 4—ft.
Set between 3�,� ft.and��ft. FITTINGS:
STATIC WATER LEVEL p
FORMATION LOG COLOR HARDNESS OF FROM TO O1 ft. .�8.below ; above land surface Date measured � 2 �2
FORMATION
PUMPING LEVEL(below land suAace)
�i18 brown 1S�C1 Q I�} 1� ft. after 6 hrs.pumping �'� q.p.m.
WELL HEAD COMPLETION
� � �� ?� �iPitlessadaptermanufacturer,.�l�t�4f$t@T' Model ��t•
1 Casing Protection
� GROUTING INFORMATION
Well grouted? �}l Yes G No
Grout Material �'}�Neat cement�Bentonite
tt1C��t Cp�^�-,-'��lt from��S��. to�tt. yds. 'J bags
[�IItOt11t� from JL to iJV ft. ��yds. ❑ bags
from to ft. ❑ yds. ❑ bags
NEAREST SOURCE OF POSSIBLE CONTAMINATION
5� feet I]flI�11 direction SE"p�iC type
Well disinfected upon completion? T� Yes ❑ No
PUMP
f�Not installed Date installed �f 3 j9�
Manufacturer's name l��rc
Modelnumber�3tQT'g HP 31�_Vol[s
Length of drop pipe �l6 ft. Capaciry�� p.m.
Pressure Tank Capacity
Type:,� Submersible � L.S.Turbine 'J Reciprocating ❑ Jet C
ABANDONED WELLS
Not in use and not sealed well on property? ❑ Yes ��[lo
WELL CONTRACTOR CERTIfICATION
This well was drilled under my jurisdication and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Useaseaondsheeti�needed Bergerson--i:aswell. �iAC. �7.�'J�`�
REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No.
� ' � ' 7�2�9� �
Authorized RepreSentative$�ganture Date
��TZ'1S SCtfUZt2 7�2��2
Name olOnller Date f
�OCAL COPY �# C.1 � (j � � ME-01205-03(Rev.9/91)