HomeMy WebLinkAboutWell and boring record MINNESOTA UNIQUE WELL
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County Name WELL AND BORING CONSTRUCTION RECORD C
Minnesota Statutes,chapter 1031
Hennepin
Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED
rOono ry r?c V4 I/4 V., it. 9 i 1.i fJ 2 I,S
GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD
Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary
❑Auger n Rotary ❑Rotasonic
House Number,Street Name,City,and ZIP Code of Well Location ❑Other
3 VI5 ?^ , ' -r•e-t 9 ' r o r 5 s? DRILLING FLUID Wilt HYDROFRACTURED? ❑Yes ❑No
Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. From ft.To ft.
Showing property lines,
N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling
1 1 1 i t
j 1 i : I I �%. ' y� ' ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
Li\.. j ❑Community PWS ❑Dewatering ❑Remedial
-�- + F -I-- _... 1 ❑Elevator ❑
W E J {j CASING MATERIAL
T Qw Drive Shoe? ❑Yes No HOLE DIAM.
- -T r -` ❑Steel ❑Threaded ❑Welded
/z Mile ❑Plastic ❑
1 I I 1
'- -'- ' 1 CASING
' g ' ' Diameter Weight Specifications
I 1 Mile I in.To ft. lbs./ft. in.To ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. ` ` in.To ft.
i t. in.To ft. lbs./ft. in.To ft.
r
- e rid s3[ On e S yes - OPEN HOLE
Property owner's mailing address if different than well location address indicated above. SCREEN
.J -
t Make f T: 01"I From ft. To ft.
15250 Wayzata Blvd Type stainless Diam. '.
i,Ja y z a t a MN 55391 Slot/Gauze . 15 Length 7 '
Set between 1 95 ft.andl 95 ft. FITTINGS
STATIC WATER LEVEL //� 60 ft. LJ Below ❑Above land surface
Date measured 9/1 4•1)2 3 Dry hole ❑Yes E]No
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
ft.after 2 hrs.pumping g.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
0 Pitless/adapter manufacturer monitor u.1 ftld'3iel
❑Casing protection X 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[l -'.rom 185 To 5 ft. ❑Yds. ❑Bags
Material b e n.t o n i from 50 To 0 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
Brown
Well is feet _- direction from type
Well disinfected upon completion? ❑Yes ❑No
,.,ia /Sa.nd Cray. S 25 1 ''',
PUMP
❑Not installed Date installed 9/2 6 12 3 am /Grave 1 ' I 18 z ':T _
_ 5 .: r
Manufacturer's name
j 30
Model Number HP - ' Volts
Length of drop pipe ft. Capacity g.p.m.
Type:[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 1j 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 Stodola Well Dril1in Cc Inc 1691
Licensee Business Name Lic.or Reg.No.
." 55' /2 /2'
Certified Representative Signature Certified Rep.No. Date
LOCAL COPY 8 694 21 Rob StodolaName of Driller
ID#52603 HE-01205-18(Rev.3/19)