HomeMy WebLinkAbout12-31-22 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 �- 8Minnesota Statutes,chapter 1031 6 6 -
Township Name Township No. Range No. Section No. Fraction(sm. - +lg.) I WELL/BORING DEPTH(completed) DATE WORK COMPLETED
1 1 7 1' '/a /a ft. 'I 2/31 .(1'7
GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD
Latitude Longitude- E Cable Tool E.Driven 7 Dual Rotary
❑Auger ❑Rotary [ Rotasonic
House Number,Street Name,City,and ZIP Code of Well Location ❑',Other
•sq�? _ r 3],�,. ' ; rZ CO P n DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No
Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. T'*-r,t-r-.;_,-: f"r:, From ft.To ft. 1
Showing property lines,
N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling
._fl -- ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
��� �,.� 9:j I;.1. }
▪ � � � e: � LI/
� ..,.. ❑Community PW5 ❑Dewatering ❑Remedial
---+--- ❑Elevator ❑
w ECASING MATERIAL HOLE DIAM.
T
Drive Shoe. ❑Yes ❑No
▪ --T---r ❑Steel ❑Threaded ❑Welded
1 I
/z Mile I ❑Plastic ❑
ICASING
s 1 Diameter Weight Specifications
j 1 Mile j 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.
e8e1 C O sc
fi SCREEN `�' OPEN HOLE
Property owner's mailing address if different than well location address indicated above.
Make Jo I S O I_"? From ft. To ft.
650 Bunker Lake Blvd NW 7
Anoka, MN Slot/Gauze •1 2 Length I
Set between )il ft.and 1 6 2 ft- FITTINGS II
STATIC WATER LEVEL/ . / ? ft. ❑Below ❑Above land surface
Date measured 1 1/ 1 / 2 2 _ Dry hole ❑ Yes ❑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 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 .711#' t 1 From 1 54. To ft. ❑Yds. ❑Bags
Material 0 From 5 C To ft. ❑Yds. ❑Bags
HARDNESS OF Material From To ft. ElYds. ❑Bags
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag94 lbs.cement
Driven casing seal From To Bags =
or 50 lbs.bentonite
NEAREST KNOWN SOURCE OF CONTAMINATION
Clay Well is _feet direction from type
Well disinfected upon completion? ❑Yes ❑No
-r PUMP
T
/3 a n
❑Not installed Date installed .
7'Cave 1!-a#-- 7 Manufacturer's name •^-e C
1
Model Number HP _- • • Volts
rinry
'' .-Ca °? 9'f Length of drop pipe ft. Capacity g.p.m.
y ;^....., off L 1 1 Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
ABANDONED WELLS
land ^d, Does property have any not in use and not sealed well(s)? ❑Yes 1R.No
VARIANCE
l ''rav 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.
°_on c 3-r' nl a 'Tra1-.?, nri 1 1 i n ('r^ti
Licensee Business Name Lic.or Reg.No.
Certified Representative Signature Certified Rep.No. Date
LOCAL COPY P
Name of Driller
ID#52603 HE-01205-18(Rev.3/19)