HomeMy WebLinkAbout09-30-22 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 8 4 H 5 7
Rennepin
Minnesota Statutes,chapter 1031
Township Name Township No. Range No. Section No. Fraction(sm.--+lg.) WELLBORING DEPTH(completed) DATE WORK COMPLETED
Orono 117 '1 08 NW NW NNA _ 7„ ". 9/30/22
GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD
Latitude Longitude ❑Cable Tool R Driven ❑Dual Rotary
❑Auger Rotary ❑Rotasonic
House Number,Street Name,City,and ZIP Code of Well Location ❑Other
1040 Loa Linda, Orono 5 364 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ]No
Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. Be tit tin i t e From ft.To ft.
Showing property lines,
roads,buildings,and direction. USE
NI Domestic ❑Monitoring ❑Heating/Cooling
❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
IElCommunity PWS ❑Dewatering ❑Remedial
}' ❑Elevator Liw ET ,L CASING MATERIAL Drive Shoe? ❑Yes [ No HOLE DIAM.
t V ❑Steel ❑Threaded ❑Welded
'k Mile °,, ,../
� [Plastic ❑
-,, ' CASING
' g ''' y Diameter Weight Specifications
1 1 Mile in.To ft. lbs./ft. in.To, ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.To; ft. lbs./ft. �' in.To .
Fox
in.To ft. lbs./ft. in.To ft.
A_
SCREE .J' r OPEN HOLE
Property owner's mailing address if different than well location address indicated above. N s c v
Make "r From ft. To ft.
Wayzata
Blvd
Type s t as I n e s s Diam. `f. " t�
Suite 15 Slot/Gauze •12 Length 8' t
"Innetonka 55105 Set between 160 ft.and 65 ft�. FITTINGS 3' i' d
STATIC WATER LEVEL
/y / it 5 ft. ]Below ❑Above land surface
Date measured 9/ 3 0 J 22 Dry hole ❑Yes l]No
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
ft.after hrs.pumping g.p.m.
2
Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
xi Pitless/adapter manufacturer Monitor
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)
Materialtt bentonrom 1?.-' to ft. ❑Yds. ❑Bags
Material From To ft. - ❑Yds. J Bags
HARDNESS OF Material From To ft. ❑Yds. ❑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 air e 5 t e r.1
Clay 7trown, 1k4 0 2 q Well is feet `' direction from city sewer
p
Well disinfected upon completion? ]Yes ❑No
Slay/Sand. Gray 1 29 102 PUMP
❑Not installed Date installed
Sand. T Gravel Mix 9 102 112 Manufacturer's name Shafer
Model Number HP Volta
Fine Sand Gray S 117 156Length pipe 4 ft. Capacity m.
9 P PiP P y g•p
Type:y]Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
Sand Brown S 156 1 {0 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. n Stools Well Drilling Co. ,Inc. 1691
Licensee Business Name Lic.or Reg.No.
55 1-cliVV27.
l `d Aepresentati re ignature. Certified Rep.No. Date
LOCAL COPY 848573 Name of Driller
iD#52603 HE-01205-18(Rev.3/19) _