HomeMy WebLinkAboutWell info STATE OP MINNESOTA GEPARTMENT OF HEALTH
1. OCATION F WELL �� ,L//A'NESOTA UN/QUE WELL NO. A 7 7 4 Q 9
County Name _ WATER INELL RECORD
/]�,� ,�, Minnesala Slnlules 156A.01-.08 fos Wa[rs Sample �#
�..+�"�"'.'.. �f.I�'�-�,
Township Na e � Township Number Range Number Sec[ion No. Fraclion 4.WELI,DEPTH(completedl Date ot Completion
E
�� ���-�- ! / 7 � �� f p ��.,,,5� �, �..�''� /� f� S , ?� �
Numerical Stree[Address and City of Well Location or Distance from Road Intersection. 5. DRILLING METHOD
���� �-- ❑Cable'lool ❑Reverse ❑Driven ❑Dug {
! ,-... ;�- ..�} ...._,
Show exact oca[ion ot well in section grid wi[ ' . � ,Sketch map of well location. ❑HollowKod ❑Air ❑Bored ❑
N f j;7
� � i i Addition Name i%��� �-^�-a.,..,,,,,.., �Rotary ❑Jened ❑Power Auger
--r--�- -1 -1- � � � 6.DRILLWGFLUID
�"
� ' i 1
._y_ ___ _ �_ Block Number �,
yy i ;�! i � E � � 7. USE
i
_1_ ___ _,_ __ � �i Domestic ❑Monitonng ❑Heat Pump
I � � I Lot Number O Irrigation �❑Public ❑Industry
f-mi. �,.i
� i i � - ❑Test Well {]Municipal O Commercial
--�- �- - -r- „g'� � ❑AirConditioning ❑
� , ' � � fi ... �,.�-
� , L J��-��"°"°�"� g,CASING HOLE DIAM. �
�'—1 milE'—� "_" - i
2.PROPERTY OWNER'�AM� Mailing Address if different than propeRy address ❑g�ack HEIGHT:Above/Below �
❑Threaded
� iodicated above. Surtace h.
❑Galv. ❑Welded C
Drive Shce? Yes—No�
� �Plas[ic O �-+;�
� � -� . .�_.�in.to /�!` tt. Weight�IbsJft. .�' n. to,� v rt.
3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight IbsJ(t. �in. to«1t.
FORMAI'ION
in.to fL Weight IbsJtt. _�n. to_�t. -
.,,�� J� �',..�`..r, r� ;, � � � 9.SCREEN Or�open hole
._ ' '�� (rom (t.[o. ([.
Make �
n r� ,/ '[ n } -.�-.
� -(..�G� ��'i-R^9� Y� � { TYPe �,�j�._. .�1�.� �.�1 t{� Diam. �,
!,.�
SIoVGauze f �- Length�
a F TINGS:
; �� � - L j� �'i-.-� �1� �� Set brtween�ft.and���ft.
�qp-� I0. STATIC/WATER LEVEL
�;�,.�,�,_:;� ti n � ��s �`� / v �f r� L'/ � ft.gbeluw ❑abo�•e Date Measured � � -f� �.,�
lan surtace
R�� 1l. PUMPING LEVEL(below land sur(ace)
1. p /
'f',�.^''';.:...3,-,p„_!� :,.e,,Yv"..! �8....�'' f s ! �� z fL atter�hrs.pumping , d B.p.m. �
ft.after hrs.pumping g.p.m. �
12.HEAD WELL COMPLE"1'ION }�-
RPitless adapter manu(acturer ��`�'��-•'��ti"� Model_�._�S�_�-_ -
'O Basement,o((set ❑At least 1'L"abuve ground
❑Plastic casing protection
13. WELLGROUTED? ❑Yes ❑No
� �Neat Cement ❑Bentonite ❑
Grout material trom ��,• to�_—ft.cu.yds. _
�;.
t ;
la. Nt:AREST SOURCES OF POSSBLE CONTAMWATION� . ,P r
�V �'..._i _ . ���l(eet �1--4aL direction 3`����'-�" "�'ti' .v.� �YPe
Well disintected upon completion? �1'es O Nu °� ,�li:rz��,�
lu. NUMP
� .��A Uate installed �� � � �� O Nol installed
�. s
����� � Manu(acturer's name ' �'�-"4i'-�7'�-
Madel number � � �" � HP ��1 Vol[sv i��
Ixngth of drop pipe �u (l. Capacity � � g.p.m.
Material of drop pipe ��"'�"
Type: �Submersible ❑L.S.Turbine O Reciprocating
❑Jet ❑Cen[rifugal �O -
16. ABANDONED WELIS
Unused well on property? �,Yes ❑No
(:se a srrond sheef,ij needed Sealed Permanent ❑ Temporary ❑ Yot sealed
17. REMARKS.ELEVATION,SOIIIZCE OF DA7'A,etc.
� I8.WATER WELL CONTRACTOR CENTIFICATION
This well was drilled under my jurisdiction and this report is true to the hest of my
� knowledge and belie(.
/i' .r�`.S r`., ,�-U�.-'�.-C,�� i 4 > 7.� 7 L
� Licensee Business Name ` . Li�ens�e rN�a. /
Address �/t�� „�Q �•�- y�.�..9' Y°'v�r/�, t-�, , .t-L-,.fy� f.
�� {�`'
Signed�r-�- `�r;-�'LR..�Z{ Date�� /f � �j
�^
Au(horized f2epresentafiue
��, ,�.. .�'� .-�;,,, ;_ � Uate ' �'�
�� Nn me of (Ier
5/74 30M
� � � �o � 7/76 30M �
LOCAL COPY HE-01205-03(Rev.9/88) 2/8230M
� STATE OF MINNESOTA DEPARTMEN�...QF HEALTH �
!�en�Ecbkb`�`°:,
1. LOCA710N OF YELL M(enEe�lank N fQ oE W own)N0.
Gounty Name U _.
�L.:._
Township Name Townzh Number Range Number Section No. Fraction 4. WELL OEPTH (complettd) Date sealed
E h +� o f 'y
� ��"``/r P/ sr �-� �j ! C� �� fc. y..� _ lC,` �,i
��' \
�., V
NUmerical Street Address and City of Neli Location or Oistance �`ri d 5. DRILLING METHOD (if knoxn)
Intersection �� 1�Cable tooT 4[�Reverse 7[]Driven IC�Dug
���� �� , � 2[J Nollaw Rod 5[]Air 8�]Bored 11[]
;hoa ezatt location of well
30 Rotary 6�Jetted 50 Power Auger
(in sectton grid �ith "X") Sketch map af well location 6. OBSTRUCTIONS
� Mell obstructedc�.Yes � No
_ � _ _ _ ;_ _. _ 2�� � Obstructtons removed�]Yes (]No If obstructions cannot be
� � � ' � removed, contact MDH
, > ��
y� _ ; ; y _I_ � _ E O� before sealing.
_ , , � � j �. �SE
" '- ' '' ' 4.,�, s� 1]�6omestic 9[�Monitoring 80 Heat Loop
_
; _; _ ; : I ('(� 20 Irrigation 50 PubliC 90 Industry
1 % 3[J Test iiell 6(]Huniclpal 1C[]Commercial
s �
� 1 +�L 7�A1r Conditioning 11[]
2. PROPERTY OWNER'S(�NAME Ma111ng Address if dlfferent than 8: CASING(S) �
� � y M property address indtcated above 1�Black 4�Threa.ded 7(]
�Cl
2[�6alv. 5[�Welded
3L]Plastic 6�;tainless Steel �
HARONESS OF
3. FORMATIOH lOG COLOR FORMATION FRON Tp �Tn. to�ft. ,
If not known, indicate formation log fram new well or nearby wello 1n. to ft.
9. SCREEN /�
�Screened well from��ft. t67�_ ft.
— — — (I' known) I
C J ❑Open Hole fron ft, to ft.
10. STATIC WA7ER LEVEL
�� ft. � below (�above
land surface Date Measured
11. 41ElLHEAD COMPI.ETION
1� Pitless Adapter 40 Found Buried
� 2(�Basement offset '�
3�Well Pit
16. REMARKS, ELEYATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC.
12. GROUTIN6 INFORWITION
l�j-Neat Cement 2[]8entonite �
Grout material � from�to� ft. cu. yds
�
i — —
� 13. MEAREST SOURCES OF CONTAMINATION �
/'U feet y��_ directlan '��_'�'7�='—tYPe
Well disinfected before sealingt Q] Yes
14. PUMP �Reoaved �Not Present
Type: 1[I Submersible 3�L.S. Turbine '.�(Reciprocating
�Jet 40 Centrifugal 60
15. EXISTING WELLS (Please sketch locattans of abandoned and
I active we11s in remarks section or on back,)
Other unused w�ll(s) an propertyt �Yes � No
Abandoned: [] PermanenY �Temporary �Not sealed
17. NATER uELI CONTRACTORS CERTIFICATION
This well was sealed under my Jurisdiction and this report
is true to the bes of my knovrledge and belief,
�- . w J7 > 7 �
Llcensee Business Name � ��tcens N
C
�-- •
Address
Signed�ve ✓�_Date .r-�7 c!
Date �� - �
FFICIAI ABAIIpONED 4ELL RECORD (May br used for CroDerty Transfer) Name of 111er
ZXPCYtTA1VT: PZLS WITH DSBD .