HomeMy WebLinkAboutWell record MINNESOTA UNIQUE WELL
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County Name WELL AND BORING CONSTRUCTION RECORD
Minnesota Statutes,chapter 103I
Township Name Township No. Range No. Section No. Fraction(sm.—►lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED
1 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. - From ft.To ft.
Showing property lines,
roads,buildings,and direction. USE N CI Domestic ❑Monitoring ❑Heating/Cooling
I I I
J L ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
_
' ❑Community PWS ❑Dewatering ❑Remedial
❑Elevator ❑
W E CASING MATERIAL Drive Shoe? ❑Yes [No HOLE DIAM.
'---T---r T
, ❑Steel ❑Threaded ❑Welded
'/z Mile ❑Plastic ❑
1I CASING
1 Diameter Weight Specifications
S
1 Mile I •• in.To ft. lbs./ft. in.To' ft.
3 ,»
in.To ft. lbs./ft. in.To' ft.
PROPERTY OWNER'S NAME/COMPANY NAME
in.To ft. lbs./ft. in.To ft.
:�Y
OPEN HOLE
Property owner's mailing address if different than well location address indicated above.
SCREEN y e s
Make johnsOn From ft. To ft.
Type stainless Diem.
' ',
� Slot/Gauze ' �� Length _
Set between 148 h.and 158 ft. FITTINGS . 1 1 > ,
STATIC WATER LEVEL j ,6 0 ft. 0 Below ❑Above land surface
Date measured 3 r/�2 3 r 2 3 Dry hole ❑Yes ❑Mo
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
g t, 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
Ef Pitless/adapter manufacturer j i t e wa.t:e r 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 C U t t i f g rom 148 To -,`. ft. ❑Yds. ❑Bags
Material b e f t O n i r 50 To ft. ❑Yds. ❑Bags
Material From To ft. ❑Yds. ❑Bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO One bag=94 lbs.cement
MATERIAL Driven casing seal From To Bags or 50 lbs.bentonite
NEAREST KNOWN SOURCE OF CONTAMINATION
Clay Brown ' Well is _ _feet _. direction from type
Well disinfected upon completion? Er.Yes ❑No
Clay/Sand Gray S 1 PUMP )
❑Not installed Date installed 9/6 i 2 3
C?p Sand r .3 Shafer
.''s r O C Manufacturer's name
Fine Model Number HP I Y
• Volts
Silty Clay/Sand Gray s fi Length of drop pipe ft. Capacity g.p.m.
t , s ,,,., Type:D&ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
Gravel i.x n r. ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑Yes ❑ fo
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes [S 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.
.7!-toctola Well T.rillin 17,7
Licensee Business Name Lic.or Reg.No.
77,7-..e.(‘,„,---„,--- 727,,,,..' -, .- '*--' - - ,
Cerfified'Representative Signature' Certified Rep.No. Date
LOCAL COPY 8 6 9 4 2 8 Name of Driller
-52603 HE-01205-18(Rev.3/19)