HomeMy WebLinkAbout2000-well & boring record WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 6 4 2 9 7�
Hennepin Minnesota Statutes Chapter f031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
n.
Orono 117 23 30 NW�,SE,.AiW ,,. 168 6/04/dfl
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
2120 Carzis e L�tle s �ono, MN 5532 ❑ CableTool ❑ Driven ❑ Dug
g ❑ Auger [�Rotary ❑ Jetted
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
_� � � �_ r.c����� water FROM h �o n.
i -i- -i- -, �.
USE ❑ Monitoring ❑ Heating/Cooling
� � i � Domestic ❑ Communi PWS
�- ❑ Irrigation �' ❑ Industry/Commercial
� i -� i `.. ❑ NoncommunityPWS ❑ Remedial
yr E T �� ❑ Environ.Bore Hole
i � � � ,� . . ❑ Dewatering ❑
i i i r '/zIM.1e j�L�� CASING Drive Shoe? ❑ Yes CXNo HOLE DIAM. .�
� � � f�EJ.:I�-� ❑ Steel ❑ Threaded ❑ Welded (
- -L- -�-
i - i- i i
� Plastic ❑ a�np[1
s
�-1 Mile-�
� � � CASING DIAMETER WEIGHT
PROPERTY OWNEfI'S NAME �i in.to 163 ft. Ibs./ft. ��.td�s ft.
Pillttr Hotge s ��.�o- __—n. ib5.in. �y colb$_n.
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft.
.__,. 1'15 Lgk� StLC�,a� W• SCREEN jf�a OPEN HOLE
WB�ZdtS� A�t 55391 Make j.'Q from ft.to ft.
Type Diam.
SIoUGauze 1 Length
Set between �3 fl.and��ft. FITTINGS: � PRC�P_T
STATIC WATER LEVEL
WELL OWNER'S NAME Sd ft.� below ❑ above land surface Date measured 4!4/d0
- Piliar �O�S PUMPING LEVEL(below land surface) n�
�
Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping g.p.m.
WELL HEAD COMPLETION �
][I Pitlessadap[ermanufacturer�$$g Model b��
❑ Casing Protection � 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? � Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement �I Bentonite O Concrete ❑ High Solids Bentonite
MATERIAL
from_�_to_��ft. � p yds.XI bags
from [o ft. ❑ yds. ❑ bags
Ci�R31 Yel3ov d ZS from ro ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION Tk ��
C2ay Grmp 15 5� teet direction __ type
Well disinfected upon completion? ❑ Yes ❑ No
Clay b Gravel Gray SO 79 PUMP 4/16/OD
❑ Not installed Date installed
ri�.Ay Gray 79 I11 ManufacturePs name _ �eL8
Model number HP 1 Volts
Clap � Gravel Red 111 160 Length of drop pipe 80 tt. Capaciry 2d g.p.m.
Gravel � S�nd ��'d 16� ibg Type l�(Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS [T11 OidL1
Does propeRy have any not in use and not sealed well(s)? ❑ Ves ❑ No
VARIANCE
Was a variance granted from the MDH foi this well? ❑ Yes ❑ No TN#
WELL CONTRACTOR CERTIFICATION
Use a second sheet,il needed 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.
Stevens Dri121ng & Env. Services 86654
Licensee Business Name Lic.or Reg.No.
_`
Authorized Representative Signature Date
��ay .rot�soa �/oa/oo
Name ol Driller Date
LOCAL COPY '�j 4 2 9 7 6 HE-01205-07(Rev.2/99)