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HomeMy WebLinkAboutUntitled MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name 'WELL AND BORING CONSTRUCTIONTRECORD f 4 ��; yl P5v\a p 10 Minnesota Statutes,chapter 1031 Township Name Township No. Range No. Section No. Fraction(sm.- .lg.) WELL/BORING DEPTH(completed) DATE WORK C MPLETED Orono t t1 23 Io E 5. 4 N } 125 ii. I is D,-j - 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 ti 1 2,i1 La k V ICI w Ave. O, Dino 55 3C I DRILLING FLUID WELL HYDROFRACTURED? ❑Yes X No Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. ti A-or11 I . From ft.To ft. Showing property lines, roads,buildings,and direction. USE N -sfil Domestic ❑Monitoring ❑Heating/Cooling I I I I 17\1 _J_ L ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial �` ❑Community PWS ❑Dewatering ElRemedial _ ___ ___F_—I— ❑Elevator ❑ w ET CASING MATERIAL Drive Shoe? ❑Yes X No HOLE DIAM. '' j ❑Steel ❑Threaded ❑Welded . 'I 'h Mile 7 Plastic ❑ -.j CASING J s _ _ _ - Diam�e{ter - - —Weight Specifications 1 I 1 Mile ❑ � -' r{ in.To '15 tt. lbs./ft. `/ in.To 50 ft. _,; PRO PPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. ;I Z in.To' ft. Je-nnt cc)," JV 3 in.To ft. lbs./ft. in.To ft. i Property owners mailing address if different than well location address indicated above. SCREEN 1f'S OPEN HOLE I Make .)C'\V\CO f-1 From ft. To ft. SO. e, Type min I yl Ve S5 Diam. 2 1 Slot/Gauze Length 1 Set between I I b. ft.and 12 5 ft. FITTINGS PG 6 STATIC WATER LEVEL ft. [F1 Below ❑Above land surface ! t i Date measured ' 'Z` ' Dry hole ❑Yes ❑No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ft.after �' hrs.pumping 5o q.p.m. 1 Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION J� 1 Pitless/adapter manufacturer 1"t i F'n I ( Model ❑Casing protection X12 in.above grade I ❑At-grade ❑Well House ❑Hand Pump J • GROUT,INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) J 1 1 Materia..,[U� 11I'1t�S From 1 I S To 50 ft. 7 ❑Yds. ❑Bags Material Jf t1 I to From 1%7 To O. ft. 3 ❑Yds. ©Bags HARDNESS OF Material From To ft. ElYds. ❑Bags I GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement or 50 lbs.bentonite NEAREST KNOWN CSSOURCEOFCONTAMINATION �I t j' et1.')e tr L`tf a- {it kitl \ `i J 6F\ r I,ry 11( ,:.d'- 0 )Li Well is feet direction from Cii If le de CI type // i } /yu� Well disinfected upon completion? 'Q Yes ❑No II \_ 6.t t (HI"({-`1 Gx�1 i ! PUMP (� y, ) ❑Not installed Date installed �' 1 C ELL ( 1.\ L...-)Y cc) t Sa -ILt 1 1- Manufacturer's name 51 V a k l 1'1 C, \. Model Number 1.- HP Volts 1 Length of drop pipe f� ft. Capacity g.p.m xy.'": ' Type:Xc Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ A ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes No 1 VARIANCE 'I Was a variance granted from the MDH for this well? ❑Yes %No TN# 1 WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725. i 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. ` Iy 11\ StoAC\(., \I\JQk\ V1,I\Inc) 1‘411 Licensee Business Name Lic.or Reg.No. I .. .v.:-.5 - I 1 15\ LI Z. '4-..),, . ,...„,- - ertified Representative Signature Certified Rep.No. Date -, i� d t`''�1 I 1 LOCAL COPY 8 7 3 5 4 9 d Name of Driller ID 852603 - HE-01205-18(Rev.3/19) ,41