HomeMy WebLinkAbout3400 Fox Street - Well Permits - Well Construction Record 10-3-25 MINNESOTA UNIQUE WELL
WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
County Name WELL AND BORING CONSTRUCTION RECORD 8 9 410 6
Minnesota Statutes,chapter 1031
Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED
V.
/ ft.
GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD
Latitude Longitude ❑Cable Tool ❑Driven- ❑Dual Rotary
❑Auger E 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,
N roads,buildings,and direction. USE IN,
Domestic ❑Monitoring ❑Heating/Cooling
-- -----1-----------1--. ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial
L _ ❑Community PWS El Dewatering ❑Remedial
❑Elevator ❑
W E
T CASING MATERIAL Drive Shoe? ❑Yes ❑No HOLE DIAM.
�n Steel El Threaded ❑Welded
1/2Mile h r}5 ❑
1 LLLJJJ Plastic
T CASING
s DiameterS Weight Specifications
I 1 Mile I 4i in.To V ft. lbs./ft. in.To ft.
PROPERTY OWNER'S NAME/COMPANY NAME 4 in.To ft. lbs./ft. in.To ft.
in.To ft. lbs./ft. in.To ft.
Property owner's mailing address if different than well location address indicated above.
SCREEN OPEN HOLE
Make From ft. To ft.
Type Diam.
SIoVGauze Length
Set between ft.and ft. FITTINGS
STATIC WATER LEVEL ft. ❑Below ❑Above land surface
Date measured Dry hole ❑Yes It'No
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
ft.after 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 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 From To ft. ❑Yds. ❑Bags
Material From To ft. ❑Yds. E Bags
HARDNESS OF Material From To ft. ❑Yds. ❑Bags
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags -
One bag94 lbs.cement
or 50 lbs.bentonite
-
NEAREST KNOWN SOURCE OF CONTAMINATION
Well is feet direction from type
Well disinfected upon completion? Ill'Yes ❑No
• PUMP
❑Not installed Date installed
Manufacturer's name
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 ❑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.
Licensee Business Name Lic.or Reg.No.
r/ r
Certified Representative Signature . Certified Rep.No. Date
LOCAL COPY 894106 Name of Driller
ID#52603 HE-01205-18(Rev.11/2022)