HomeMy WebLinkAboutWell info STATE OF M[NNESOTA DEPAR7'MENT OF HEALTH ��
l.LOCATION F WELL � ,Nl.NNESOTA UA7QUE WELL NO. ������
Counry Name WATER WEtL RECORD
r` � �Ninaeso[a S[afufes 156A.07�.08 fo>Water Sample
--�� ,.,ti "bi
Township Nam � Township Number Hange Number Section No. Fraclion 4. WELL DEPTH Icomplettdi Date o(Completion
._ N E � - � �.��
v� i �i�
t�'� �:,: �i/�✓1> ! � s 2 w '�� �" _ �r� _ n. . �'/
Numerical Street Address and City of Well Location or Distance from Road Intersection. 5. DRILLING METHOD
� � � �,. f. ❑Cable"lail ❑Reverse ❑Uriven ❑Dug
i ( t / ^ .f ..'!'.� •'t.,...,
� $how exacl Iceation ot wel'in sec� grid with"X." Sketch map o(well locatioa O Holluw Kud ❑Air �Hored ❑
�; N
� � i Addition Name +...� `[/�� otary ❑Jetted ❑Power Auqer
--r-'y- -� -1- '�� 1�,,.� 6. URILLING F'I.UfD
� � � � Block Number � /
w '-+- -7- - �- � j 7. USE �
� I �
�
_1_ _3_ _,_ __ T � � �1 j J f$Domesuc ❑Momtonng ❑Heat Pump
I , i � I Lot Number t ,„ � p ❑Irngation ❑Publk ❑Industry
f�mi. t (
a�� _�__�,( �"I'est Well {]Municipal ❑Commercial
--�- -�- � -r- I `4---�+^*"'"'""'" t ❑AirConditioning ❑
' � � � j
�1 milr� 8.CASING HOLE DIAM.
2.PROPERTY OWNER'S NAME Mailing Address if differen[than property address ���a�k HEIGHT:Above/Below
❑7'hreaded
=-r-� indicated above. Surtace ft.
�;;''`'�r;'� �,r . ❑Galv. ❑Welded
- � Drive Shce? Yes_ No—
`,_ ,,; f�Plastic ❑
�� r � y "�"
'' t' ..�"'��i"� �in.to ��T tt. Weigh[�Jef�IbsJfL �in. to-�t.
3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight IbsJft. y�n. t�t.
FORMATION
in.to fL Weight Ibs./ft. —�n. to�t.
�'� ��� -� � .
,�,,.p,,,�..�„ :'t:t.,. - l` � 9.SCREEN Or open hole
' -'� Make �� ���� - r-»-� from ft.to. ft.
�'�" � ' �-. � r` -+ � � � ,t
��el'' . '�:r±. �.'ti..r� . ✓ l e�� Type_�� f�_yd� � i�� Diam. -+
' . SbVGauze f�,�I I.ength�
� FI INGS:
,,.�'_.f : -_.�-. . , ,�A"�� �" �� Set between�tt.and�ft. �
10. STATIC WATEK LEVEL {.
�y '-� ft.;�below ❑aboce Dale Measund A� - "�� ('�/
land surtace
11. PUMPING LEVEL(below land sur(ace) �
� r/tt.a(ter—.._.�hrs.pumping -1 � g.p.m.
(t.after hrs.pumping g.p.m.
1'L. HEAU WF,LL COMPLE7'ION �^
{�itlessadaptermanu(acturer ��,�--I�'^^----^�^' Medel j� ' �t
'.O Basement,o((set O At least 1'L"above ground �
❑Plastic casing prolection
1"3. WELL GROUTED? G�+Yes ❑No
� �Neat Cement ❑Benronite ❑
-..nc
� Grout material from{..�.a. to—r4�—f[.cu.yds. _
i-
��� .�� ^
, `
14. NF.AREST SOL'RCES OF POSSIBLE CONTAMINATION
_ � (�(eet � direc[ion ��� � �-�„ [ype
- � Well disinfected upon completion? ,C�'es ❑No ,1�„��
� .�91 i;. i��m�v `
� Date installed (� ` �� � � ❑Not installed
- " � Manufacturer's name f }
Model num6er ^� 7>��..` HP�Volt4' ��
Length o(drop pipr �^"L ft. C apacily � r` g.p.m.
Material o(drop pipe �� -�t-..�.-
Type: �Submersible O L.S.Turbine ❑Reciprocating
❑Jei ❑Centrifugal O —
I6. ABANDONED WEL(S
Unused well on property? �Yes ❑No
Use a serond shee(.�/needed � Sealed Permanent ❑ Temporary ❑ Not scaled
l7. REMARKS,ELEVATION,SOURCE OF DATA,etc.
� 1H. WATF,R WELL CONTRACTOR CEKTIFICATION
This well was drilled under my jurisdiction and this report is true to the best o(my
knowledge and belief. �
` � .%�. t..,,..��..�.�r '�,-f" � ? .�� �
��`� `�
Licensee Basiness Name : Lirense Na. /
Address �!� �fJ f,.�' .��� r�. f �G'l�,e��f �%�l-'>,�/.-�_.
f - ."L"`. �' i f`
Signed f _ �.-.. Date �� � �f
Authon�ed Kepmsen[aflue
.�_v:._ ^ .� .. �'r �.
-� �-"-x-� Date��
� NarneofDriller
5/74 30M
� 7/76 30M
l_QCAL COPY ��7 � � � xE-ouos-os�xe�.9iss� v'sz3oM
_ _
STATE OF MINNESOTA �EPARTrfEPiT OF HEALTH
" laBANDONED NELL ItECORD
1. �xnrton oF ve��. MINNESOTA UNIQUE WELL N0.
(leave blank tf nat known) _
Cau�ty Haax ���
Townzhip Mame Townshi Numbe; Range Number Section No. Fraction 4. 41ELL DEPTH (completed) Date sealed
�rw�-�- l C 7`S� ��%� � k k of k �(-7t. �J' ' r� ` '!/
l% J C/
Numertcal Sireet Address and C1ty of Well location or Distance from Raad 5. �RZLLING METHOD (if knoxn)
Intersection Cable tool 4�Reverse 7[]Driven 10C1�ug
� P�' }� � 2f]Hollow Rod 5[]A1r �]Bored 110
7�v ���. 3[]Ratary "a 60 Jetted 9�Poaer Auger
Show exact locatton of 11
(in sectton grtd �tth "X") Sketch map of well ',:cation �% 6. OBSTRUCTIONS
N 41e11 obstructed�Yes � No
_ � _ _ _ _ ._ _� � Obstructlons remored�Yes (�No If obstructions cannot be
� � � recaved, contact MDH
' ' � � before sealtnq.
►+ - - - - • - - -I- - E
- ` . : , T —3 � �� �. �sE
' - ' ' ' y„�. I�Domestic 4❑�,nitoring 80 Heat Loop
� ' _ � I �,{f•(/�' �� 20 Irrigation �]Public 9� Industry
� ' 1 �� � 3�Test Nell 6�Municipal 1C0 Cortmercial
r--1 SL 7[]Air Condittoning 11[]_
2. PROPERTY OMNER'S NAME Mailing Address if dtfferent than 8. CASING(5) ' •
i� ,� � property address indlcated above �lack 4�Threaded 7Q
/ �--
2[(Galv. 5[�Welded
3L]Plastic 6�]Stainlesz Steel •
HARONESS OF
3. FORMATION LOG COLOR FORMATION FROH TO �in. to J� ft.
If not known, indicate formation log from new well or nearby well. in. to ft.
9. SCREEN
�Screened well from��ft. to �'ft.
�— (I` known)
�i ,f � �Open Hole from_ ft. to_ ft.
10. STATIC WATER LEVEI
��! ft.�pelow []above ,
land surface Date Mensured �1��I�
{._,. 11. WELLHEAD COHPLETION
i1� Pitless Adapter �Found Buried
�Basement offset 'j]
30 Well P1t
16. REMARKS, ELEVATTOtI, SOURCE Of DATA - CASINGS REMOYED, CASINGS PERFORATED, ETC.
12. GROUTING INFORMATION
1�-Neat Lement 2�]Bentonite �
Grout material �l from Tf to �ft. cu. yds
— — --�
13. REST SOURCES OF CONTAMINATION
v feet _� directton ��.�.,_ type
Mell disinfected before sealingt ,�Yes
14. PUMP [�,Rertqved �Not Present
Type: 1[�Submerslble 30 L.S. Turbine �Reciprocating
�,)et C�Centrifugal 6[�
15. EXISTING WELLS (Please sketch locatlons of abandoned and
active we11s 1n remarks section or on back.)
Other unused well(s) an property7 �Yes �No
Abandoned: [� Permanent �Temporary [�Not sealed
17. wATER WEIL CONTRACTORS CERTIFICATION
This well was sealed under my jurisdiction and this report
is true to the best af my knowledge and belief.
censee siness Nam n License Na.
�C.Y
Address � ,J` ' �(G�-� '
Signed c. C Date ,�-
'� �ate -' ,e '-'�j
FFICSAL ABANDONED YELL RECORD (May be used for Property Transfer) Name of ri er
IXPCYtT]IAT: PZLS (�7TH DSBD .