HomeMy WebLinkAboutwell info 9/27/23 MINNESOTA UNIQUE WELL
ELL Uri G LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County Name WELL AND BORING CONSTRUCTION RECORD - . V
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Minnesota Statutes,chapter 103I 9 1 3 &
Township Name Township No. Range No. Section No. Fraction(sm. lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED
ft.
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GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD
Latitude_ Longitude ❑Cable Tool ❑Driven ❑Dual Rotary
❑Auger ❑Rotary 1 j Rotasonic
House Number,Street Name,City,and ZIP Code of Well Location ❑Other
DRILLING FLUID WELL HYDROFRACTURED? ❑Yes E`No
Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. / "f'0 n 4 '" From ft.To ft.
Showing property lines,
N roads,buildings and direction. USE Domestic ❑Monitoring ❑Heating/Cooling
I 1 1
L El Noncommunity PWS ❑Irrigation ❑Industry/Commercial
_ 1
❑Community PWS ❑Dewatering ❑Remedial
�___ ,___�___,__ ❑Elevator ❑
W E-. CASING MATERIAL Drive Shoe? ❑Yes (j No HOLE DIAM.
T r I [ Steel ❑Threaded ❑Welded
1/2 Mile ❑Plastic ❑
i - I CASING
Diameter Weight Specifications
S
1 Mile I in.To ft. lbs./ft. in.To 5 0 ft.
PROPERTY OWNER'S NAME/COMPANY NAME _ in.To ft. lbs./ft. n.Toft.
in.To ft. lbs./ft. in.To ft.
brina ►:1leCk
Property owner's mailing address if different than well location address indicated above. SCREEN Ye s OPEN HOLE
Make Johnson From ft. To ft.
Type s t a i n l e ss' s Diam.
Slot/Gauze ' �y Length
Set between 2 00 ft.and 2 10 ft. FITTINGS lead
STATIC WATER LEVEL ft. ❑Below ❑Above land surface
Date measured 9/2 7/2 3 Dry hole ❑Yes ❑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
❑Pitless/adapter manufacturer monitor bu l IMod`el
❑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 i n ;From To ft. ❑Yds. ❑Bags
Materialh e fl t O n t From 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
Ia' Well is _ feet direction from type
Well disinfected upon completion? ❑Yes ❑No
lay PUMP❑ .Not installed Date installed /2 8/2 3
a n y Clay ;.'ray Manufacturer's name
L'"
Model Number HP Volts 2' 1 1 5
-7,and Brown 3 Length of drop pipe ft. Capacity g.p.m.
Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
-.Tine Sand Bro :) ABANDONED WELLS
Sine Silty
r Does property have any not in use and not sealed well(s)? Li Yes Li No
San .J Clay Gra.yL. 14( t.. VARIANCE
Was a variance granted from the MDH for this well? ❑Yes ❑No TN#
"'Gray. ,S _L 94 ?' i 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 ^tod.ala Uell DrillinL Co
Licensee Business Name Lic.or Reg.No.
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Certified Representative Signature Certified Rep.No. Date
'oh Stod.ola
LOCAL COPY
Name of Driller
ID#52603 HE-01205-18(Rev.3/19)