HomeMy WebLinkAbout11-02-22 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 Minnesota Statutes,chapter 1031 0 0
Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED
a ft.
GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD
Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary
❑Auger ❑Rotary ❑Rotasonic
House Number,Street Name,City,and ZIP Code of Well Location ❑Other :'1
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
I I r
J 1N ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
❑Community PWS ❑Dewatering ❑Remedial
-, -+---r- -I-- \ ❑Elevator ❑
w E T CASING MATERIALv HOLE DIAM.
Drive Shoe? ❑Yes [ No
▪- -T- - ❑Steel ❑Threaded ❑Welded
i i i '/2 Mile
❑Plastic ❑
i .
CASING
' S ' Diameter Weight Specifications
1 Mile I in.To ft. lbs./ft. in.To ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.To' ft.
in.To ft. lbs./ft. in.To ft.
;; i l l Tarr Truheck
Property owner's mailing address if different than well location address indicated above. -SCREEN 'a S OPEN HOLE
Make .oh n S o n From ft. To ft.
Type Sta.inIcP Diam. 7"
Slot/Gauze 4.15 Length T
Set between 145 ft.and ft. FITTINGS 3' lead
STATIC WATER LEVEL 77.
ft.'LJ Below ❑Above land surface
Date.measured 11/2/2 2 Dry hole ❑ Yes ❑`Ttlo
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
1`t 0 ft.after hrs.pumping g.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ,,,
▪Pitess/adapter manufacturer Model
❑Casing protection ❑12 in.above grade
❑Atgrade ❑Well House ❑Hand Pump
GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
Material ' From 1 4 5 To ft. ❑Yds. ❑Bags
'. 50
Material . .. From To ft. ❑Yds. NI Bags
HARDNESS OF Material From To ft. ❑Yds. ❑Bags
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing teal From To Bags One bag=94 lbs,cement
or 50 lbs.bentonite
NEAREST KNOWN SOURCE OF CONTAMINATION
Sand/Gravel S Well is •--1`. _. feet direction from C- type
Well disinfected upon completion? Yes ❑No
&Jaridy Clay Brown yf 42 51 PUMP
❑Not insta ilea Date installed 1 2-/6
Clay/Sand Gray 51 77 Manufacturer's name r'ha f e r
G TI f.
Model Nunher_ HP t . Volts
Clay
Length of drop pipe 1 0 r ft. Capacity g.p.m.
-x 7 Q 146 6 155 Type:❑Submersible ❑L.S.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? ❑Yes ❑No TN#
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725.
Use a second street,If needed. The information contained in this report is true to the best of my knowledge.
REMARKS,ELEVATION,SOURCE OF DATA,etc.
Licensee Business Name Lic.or Reg.No.
/,1-'Z./4-1.4: •
Ce tided epresentative Signature Certified Rep.No. Date
R, Rob Stodola
LOCAL COPY 1 4 t ` 1 F [#
Name of Driller
ID#52603 HE-01205-18(Rev.3/19)