HomeMy WebLinkAboutWell Construction Record 8-12-24 Mr/VIVEJO IA UrVIQUt WELL
WELL OR BORING LOCATION "" MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County' ame WELL AND BORING CONSTRUCTION RECORD i�) Minnesota Statutes,chapter 1031 i
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Township Name Township,No. Range No. Secti n No. Fraction(sm.—.lg.) WELUBORING DEPTH(completed) DATE WO K COM LETED
Cyr lt� 1 1' 3 ,, (;; 1 ft. ( i -�0Li
GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD
Latitude Longitude ❑Cable Tool Driven ❑Dual Rotary
•
❑Auger Rotary. ❑Rotasonic
[ House�^Number,Stre t Name,City,and ZIP Code of Well)Locationt (` _ ❑Other
ODD NA LV I L . hi.O"•r\"'" S,2 jL 1-1' _DRILLING FLUID - }{-` WELL HYDROFRACTURED? ❑Yes ❑No
Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. "'j'1'}�)` t
Showing property lines, From ft.To ft.
N , roads,buildings,and direction. USE N Domestic ❑Monitoring ❑Heating/Cooling
I I I I 1A`j
-_-_1_._L 1 ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
❑Community PWS ❑Dewatering ❑Remedial
X ❑Elevator ❑
w i E T CASING MATERIAL Drive Shoe? ❑Yes [ -No HOLE DIAM.
❑Steel ❑Threaded ❑Welded
'h Mile
Plastic ❑
I CASING
' g t Y I V Iv\ Dr, Dia Biter l i yU ft.Weight Specifications ]
0
1 1 Mlle I _ in.To lbs./ft. ! in.To ft.
in.To ft. lbs./ft. /l in.Tot ft. ,PROPERTY O(WNER'S NAME/COMPANYrr_j NAME!y p
N \1 lAct h (t u +0 I r-\ f t/ L - -4In.To ft. lbs./ft. n.To ft
SCREEN—!� �' OPEN HOLE a n it
Property owner's mailing address if different than well location address indicated above. 1 V Iy)SO . -
, ` l' "" `/-�' ` -4 f , Make _ • . 1 From ft. To F ft.
QtSI( �� J'F�! 1 IV Type ...74I().'1IY � Diam.
1^" x C e l s` r i h �� 55 3 �\ Set between
I Length I `(
t4�~ C/ a (J1 0 Set between } (� ft.and I;Si) .I ft. FITTINGS 3 ‘' 1
STATIC WATER LEVEL —* ? r
ft. a Below ❑Above land surface
g L
Date measured 'Z 2 Dry hole ❑Yes N'No
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
' ft.after. , hrsipumping q.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above. ELLHEAD COMPLETION. �r 1'p4 vie h
1 Pitless/adapter manufacture,*
er I' {V h Model
❑Casing protection 7-6 12in.above grade
❑At-grade ❑Well House ❑Hand Pump
GROUT INF. RMATION(specify be l o�itte,cement-sand,neat-cement,concrete,cuttings,or other)
Il(SS _
Material�� r From To � ft. ❑Yds. Li Bags
Material 120/1�1-4'tie- From 7 To h" ft. —3 ❑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
Lor,0 lbs.bentonit•
�/` S�I '/'.,C f NEAREST KNOWNSOURCE OF CONTAy11NATION direction from 14-i1��� type
ll is I2
0 A'1 {cf Y[D iKn— C 14 1 s Well disinfected upon completion? r Yes ❑No
/ 7 PUMP
C 1 a lr• I c A o d /�Y S ' ❑Not installed DateeinNlsta�lled.163 r��{ t
( l-.. tt Manufacturer's name " `C� - '
` r i
{ .)t l 1 l�Y tad I ` , 5 )�s ISO Model Number HP i/� Volts �3O
Length of drop pipe H ft. Capacity ;.o g.p.m.
•
-
Type:IX 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? ElYes No TN#
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725.
Use a second sheet,if needed.
The information contained in this report is true to the best of my knowledge.
REMARKS,ELEVATION,SOURCE OF DATA,etc. D014
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Licensee Business Name Lic.or Reg.No.
rrr .ee L::, '. 1t'(3) ,4
Certified Representative Signature Certified Rep.No. Date
LOCAL COPY 8 7 3 5 41 Name of Driller
ID#52603 HE-01205-18(Rev.3/19)