HomeMy WebLinkAbout12-13-2022 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 -�
6 Minnesota Statutes,chapter 1031 8 4
llennepirt
Township Name Township No. Range No. Section No. Fraction(sm. lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED
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
525 R n a h' r s t Circle, Orono DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ❑No
Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. 11,ry r i From ft.To ft.
Showing property lines, `` r
N roads,buildings,and direction. USE Domestic [1]Monitoring ❑Heating/Cooling
L ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
❑Community PWS ❑Dewatering ❑Remedial
+---�---- *` ❑Elevator
w ; - E CASING MATERIALShoe? HOLE DIAM.
T Drive ❑Yes ❑No
T r ' ❑Steel ❑Threaded ❑Welded
I
-- h Mile [Plastic II-- C CASING
S
' Diameter Weight Specifications
H1 Mile I in.To ft. lbs./ft. in.To ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.To ft.
Levitt in.To ft. lbs./ft. in.To ft.
Property owner's mailing address if different than well location address indicated above.
SCREEN } OPEN HOLE
Make L O h f S O n From ft. To ft.
3901 Su.nryside Rd #30 + Type st— less Diem. .. s
Edina, MJ T 55424 Slot/Gauze ` 4' Length
Set between 1 45 ft.and 1. 5 5 ft. FITTINGS 3 f 1 e a tw
STATIC WATER LEVEL ft. ❑Below ❑Above land surface
Date measured 12/13! 2 2 Dry hole ❑Yes ❑No
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
Swanson Homes ft.after hrs.pumping q.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION .�
1 3 60 Hamel e t Road 0 Pitless/adapter manufacturer - Model
Medina, II]Casing protection ❑12 in.above grade
❑At-grade ❑Well House ❑Hand Pump
GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other)
r
Material cuttingrom 145 To ft. ❑Yds. ❑Bags
Material e n t O n I tan 5 0 To ft. •
❑Yds. ❑Bags
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•.a1 J S EY Well is feet direction from type
Well disinfected upon completion? [ Yes ❑No
Tia j+'! San PUMP❑Not installed Date installed 12 r/1 4/2 2
. r O t' n Manufacturer's name `-'a e
..
Model Number HP.1 1//Volts 23 0
Length of drop pipe ft. Capacity g.p.m.
Type:LI 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.
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 'todola 7'heil flriil nv Co 1691
Licensee Business Name Lic.or Reg.No.
f/
I - f. 7' 1?./1. , /22
'Certified Representative Signature Certified Rep.No. Date
LOCAL COPY
Name of Driller
ID#52603 HE-01205-18(Rev.3/19)