HomeMy WebLinkAboutWell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 6 2 7 2 4 2
�r'_I2YtBp�i1 Minnesota Statutes Chapter 1031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
rono !17 23 Z A1W,,.SW,. S�?,. 1gg � 8/26/y4
House Number,Street Name,City,and Zip Code of Well Lccation or Fire Number DRILLING METHOD
825 South BYflWA ROAa 0'LO'[l0 ❑ CableTool ❑ Driven ❑ Dug
• ❑ Auger �Rotary ❑ Jetled
Show exact location of well in section grid with"X". Sketch map of well location. ❑ ;
Showing property lines,
roads and buildings. DRILLING FLUID � WELL HYDROFRACTURED? ❑YES�.NO
N
� � � � . ', , . ' Faonn n.io n.
-,- -;- -,-- -,- �.— �
�--^ � USE �^ ❑ Monitoring ❑ Heating/Cooling
� i i i �F���omestic ❑ Communit PWS
-�- -a- -�- -'- ❑ Irrigation Y ❑ Industry/Commercial
i i i i � ❑ Noncommuniry PWS ❑ Remedial
�q� E � � ^� [7 Environ.Bore Hole ❑ Dewatering ❑
i i i i
i i i i +�ZM,e {. :v"'t � � CASING Drive Shoe? ❑ Yes �No HOLE DIAM.
1 � ❑ Steel ❑ Threaded ❑ Welded
-'- -L- -'- i
� �- � � �.a�astic •l� �Iue
S �,I". �I � ,i,.,- .
�-1Mile� ..' � IJ M1�-:rP_} .j t..,L 4.: ..'l
CASING DIAMETER WEIGHT f �
PROPERTY OWNER'S NAME � in.ro 1�� ft. Ibs./ft. -�/y in.to�� ft.
Pi11�r Hc�me.s m.co ft. Ibs./ft. �m.cd�e.
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./R. in.to ft.
SCREEN �"'� OPEN HOLE
740 East Lake Stre�C Make Jav co from n.co n.
T �F.: @SCOp.Lt2g. Diam.
Gd3yz3t�, p`��I 55391 SIoUGauze 1$ Length S'
Set between ��li ft.and 1$9 ft. FITTINGS ��c3C�i
STATIC WATER LEVEL
WELL OWNER'S NAME S.�'.1 ft.�4 below ❑ above land surface Date measured
PUMPING LEVEL(below land surface)
Well owner s mailing address if different than property owner's address indicated above. ft. after hrs.pumping g.p.m.
WELL HEAD COMPLETION 4, �
� Pitless adapter manufacturer Model
❑ Casing Protection �9 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
s. GROUTING INFORMATION
1
Well grouted? C�lYes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cemen��?-BentoniLeS ❑ Concrete 3High Solids Bentonite
MATERIAL from to � ft. ❑ yds. �bags
from to ft. ❑ yds. ❑ bags
Clr�� Bi'orv�. � �'0 r�om �o n. ❑ yas. ❑ bags
/ NEAREST KNOWN SOURCE OF CONTAMINATION , �' �� +_.
C�.a�/a�S1°F? CsrE'�j' r�� �i� feet direction type
Well disinfected upon completion? �1 Yes ❑ No
G�.:2�� �2�f;�� 4l� ��� PUMP
❑ Notinstalled Dateinstalled 3��'��d�
Sand/C1ay Gray red 1t?� 13�: = y�re
Manufacturer's name
Model number HP t � � Volts
Cl�.wt F�ecl 13i 178
Length of drop pipe 1�$ ft. Capacity ��� g.p.m.
�� Siinf� :�X I7$ i�i9 Type: ❑ Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS t1
Does property have any not in use and not sealed well(s)? ❑ Yes Qi No
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes �No TN#
WEIL CONTRACTOR CERTIFICATION
Use a second sheet,ilneeded This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. -
REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge.
S�ev�a� �riZli-�s� � E�av• a7PJ. �T144.41 itiaSG -
Licensee Business Name Lic.or Reg.No.
-- ... , ��L�/oo t
Authorized Representative Signature Date
Ph;.�t ip Jt;c>
Name of Dri/ler HE 01205-06(Rev.7/98)
LOCALCOPY 627242