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Home My WebLink About09-27-22 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 6 3 Minnesota Statutes,chapter 1031 Township Narfile Township No. Range No. Section No. Fraction(sm.--.lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED j, ft. "n r n ,,..it, -ry/4 .N, r/ ? J Z GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool [f Driven ❑Dual Rotary ❑Auger in Rotary ❑I Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑Other DRILLING FLUID WELL HYDROFRACTURED? ❑Yes 10 No Show exact location of well/boring in section grst with"X.''' Sketch map of well/boring location, t Showing property lines, n © t e. From ft.To ft. N roads,buildings,and direction. USE in Domestic ❑Monitoring ❑Heating/Cooling I 1 1 I - J__-S___L I .... - -._-.. _-:_..- _- ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial I ❑Community PWS ❑Dewatering ❑Remedial -�---+- -- ---I-- , El Elevator ❑ 1 I F 1 w I I I I E CASING MATERIAL Drive Shoe? 7 Yes ❑No HOLE DIAM. -,---T- --r 0 Steel ❑Threaded ❑Welded 1 1 I 1 V Mile I I I I El Plastic El-----7- --;1*---I-1 CASING ' Diameter Weight Specifications I 1 Mile in,To ft. lbs,/ft. in.To ft. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. i .Ta` ft. t o 31'1 ca, n 1 e 1 r i k s s o n in.To ft. lbs,/ft. in.To ft. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. . Make From -. ft. To lll' ft. Type Diam. Slot/Gauze Length Set between ft.and ft. FITTINGS STATIC WATER LEVEL ?",„ ft. Q Below ❑Above land surface r� Date measured r) C 2 2 2 Dry hole ❑Yes `'No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ft.after 2 hrs.pumping 4 0 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION 'Pitless/adapter manufacturer wh i t e Wa.t e r Model ❑Casing protection 0 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 i n L From To ft. ❑Yds, ❑Bags Material Bent O n 1-`'From • To ft. ❑Yds. MBags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement or 50 lbs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION r Well is feet direction from septic type 7 / Well disinfected upon completion? N Yes ❑No r 1a..y San r ,9 f . PUMP ❑Not installed Date installed C /2 )/`�2 " Sand/Clay ray' S 2 14 fer Manufacturer's name r j ,. Model Number HP 1 • 5 VoltsV 3 0 Length of drop pipe ft. Capacity 20 g.p.m. Sandy/Clay Gray S 158 19 a Type:❑`Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Gravel ,r a 'Pik 5 192 1 Q 9 Does property have any not in use and not sealed well(s)? ❑Yes El No 7 '1 VARIANCE o C k 105 70 r 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. 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. Don Stodola Well rillire Co Licensee Business Name Lic.or Reg.No. ----I /:,/ -• -7/,. - - .- Certified Representative Signature Certified Rep.No. Date LOCAL COPY 8 6 6 J 3 Name of Driller iD#52603 HE-01205-18(Rev.3/19)