HomeMy WebLinkAbout01-16-2023 Well & Boring Construction Record MINNESOTA UNIQUE WELL
WELL OR BORING LOCA11'ON MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County Name WELL AND BORING CONSTRUCTION RECORD 6 ...
Minnesota Statutes,chapter 1031
Township Name Township No. Range No. Section No. Fraction(sm.--►lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED
IA /a la 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
DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No
Show exact location of well/boring in section grid with X." Sketch map of well/boring location. ;-,rt t 0 - From ft.To ft.
Showing property lines, •
N roads,buildings,and direction. USE M Domestic ❑Monitoring ❑Heating/Cooling
1 I —
. ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
ji ❑Community PWS ❑Dewatering E Remedial
1- + ---- - ❑Elevator ❑
w E T CASING MATERIAL Drive Shoe? ❑Yes ❑No HOLE DIAM.
-1---T-"-f' ❑Steel ❑Threaded ❑Welded
'/z Mile
❑Plastic ❑
I .-... CASING
s
i i 1 Diameter Weight Specifications
1 Mile ,' in.To ft. lbs./ft. in.To ft.
I �„
PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.To ft.
ore in.To ft. lbs./ft. in.To ft.
)` OPEN HOLE
Property owner's mailing address if different than well location address indicated above. SCREEN ,?' --'
Make . O h C:S O C? From ft. To ft.
Type stainless Diam.
Y
Slot/Gauze •1 0 Length
Set between 1 7 7 ft.and 1 8 5 ft. FITTINGS
STATIC WATER LEVEL ft. ❑Below ❑Above land surface
Date measured a / _ Dry hole ❑Yes ❑No
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
ft.after 3 hrs.pumping 0 g.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
❑':Pitless/adapter manufacturer -1,1)n 1.t or Model •'1 1 1 d O,.,
❑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 n rY 9rom 177 To :-''9 ft. ❑Yds. ❑Bags
Material 1te f t O n i tFfam 5 n 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
Well is feet direction from___ type
Well disinfected upon completion? ❑Yes ❑No
r,
PUMP
lay -,re,
❑Not installed Date installed
' r o w n 3 5 4 Manufacturer's name Shafer
Model Number HP / '' Volts •
-Si . ,' --;, '4 1 3 2, 1 3 1 2 6 ft. Capacity I ,� Gray 1" Length of drop pipe �- g.p.m.
Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
i-i ne Sand ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑Yes ❑No
7 n n 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.
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.
' ' ! " l 11n8 Co Inc
Licensee Business Name Lic.or Reg.No.
, ., /5,170 il / 1 7 i '''':'
Certified Representative Signature Certified Rep.No. Date
LOCAL COPY 0 ` * I - ,i
-` Name of Driller
ID#52603 HE-01205-18(Rev.3/19)