HomeMy WebLinkAbout10-05-22 Well & Boring Construction Record MINNESOTA UNIQUE WELL
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County Name WELL AND BORING CONSTRUCTION RECORD -- -- -- A �.
Minnesota Statutes,chapter 103I ti b b 5
Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED
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j/4 1/ i/4
GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD
Latitude Longitude ❑Cable Tool E Driven ❑Dual Rotary
❑Auger C Rotary ❑Rotasonic
House Number,Street Name,City,and ZIP Code of Well Location ❑Other
DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No
Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. '' From ft.To ft.
Showing property lines,
N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling
1 1 1 - ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
_J___1I L___
-._ El Community PWS ❑Dewatering ❑Remedial
1 1 I 1
_� CI___,_ __�___,__ ❑Elevator
w E CASING MATERIAL Drive Shoe? ❑Yes ❑No HOLE DIAM.
—,- T r I T ❑Steel ❑Threaded ❑Welded
'I/z Mile ❑Plastic ❑
-`` - ` "
1 CASING
S Diameter Weight Specifications
F-
I- 1 Mile ` in.To ft. lbs./ft. in.To ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. n.To ft.
in.To ft. lbs./ft. in.To ft.
Property owner's mailing address if different than well location address indicated above. SCREEN yes s OPEN HOLE
Make , o h n s o n From ft. To ft.
Type sta1n1'o tis Diam. '"3"I
i
Slot/Gauze •��2 Length -r
Set between 175 5 ft.and 185 ft. FITTINGS 3 t l r-,3.t
STATIC WATER LEVEL ft. ;y Below ❑Above land surface
Date measured 1 0. 5 •2 2 _ Dry hole ❑Yes IM No
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
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 wh 1 t awa t a r Model
❑Casing protection []12 in.above grade
❑At-grade ❑Well House ❑Hand Pump
GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
Material cut t 1[fig rom 175 To 4 ft. ❑Yds. ❑Bags
,denton1
Material km,, 50 To ft. ❑Yds. ❑Bags
HARDNESS OF Material From To ft. ❑Yds. ❑Bags
GEOLOGICAL MATERIALS COLOR FROM TO
MATERIAL Driven casing seal From To Bags One bag=94 lbs.cement
or 50 lbs.bentonite
NEAREST KNOWN SOURCE OF CONTAMINATION
,- Septic t e
Well is feet direction fromyp
Well disinfected upon completion? ❑Yes No
r7 1 " PUMP❑Not installed Date installed I 0/11/2
Clay/San -. Manufacturer's name S hater
Model Number HP Volts
land Brown 1 : ,
Length of drop pipe 126 ft. Capacity . g.p.m.
Type:❑Submersible ❑L.S.Turbine ❑Reciprocating El 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? ❑Yes LI No TN#_ _
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725.
The information contained in this report is true to the best of my knowledge.
Use a second sheet,if needed.
REMARKS,ELEVATION,SOURCE OF DATA,etc.
•z 11' ' 1691
Licensee Business Name Lic.or Reg.No.
' ' --
r-------:- ..
_,.
F 10/12/2,.
ert led Representative Signature Certified Rep.No. Date
LOCAL COPY 8 6 6 5 3 5 Name of Driller
ID#52603 HE-01205.18(Rev.3/19)