HomeMy WebLinkAbout2000 -Well & boring record WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
' CountyName WELL AND BORING RECORD 6 215 5 8
�����s�f� Minnesota Statutes Chapter 103/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
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House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
��..jJ Carriag� LraC1� Qr�T��J 5� 7�. ❑ CableTool ❑ Driven - ❑ Dug
❑ Auger �Rotary � ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑ _
Showing property lines,
� f� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑
rv /� Y ' tiitlt��-'�'
i , i , �FROM n.to n.
-� -i- -,-- -i- ,- - _. __
USE ❑ Monitonng ❑ Heating/Cooling
i i i i L�°Domestic
_i_ _�_ _�_ _i_ � � ❑ Community PWS ❑ Industry/Commercial
i i i i � ❑ Irrigation ❑ Noncommunit PWS�
w E T � ❑ Test Well y ❑ Remedial
i � i � "---�- -__ ❑ Dewatering ❑
i -, i -r +ZIMie '�x CASING Drive Shoe? ❑ Yes C��No HOLE DIAM.
_i_ _i_ _L_ _i_ � .i � ❑ Steel ❑ Threaded ❑ Welded
, � � � l . ,
C�Plastic ❑
S �.�
�-1 Mile-{ . . .:..... . ........ . .
'�'-+��L'-���- � CASINGDIAMETER WEIGHT
PROPERTY OWNER'S NAME � in.to ��� ft. ��� Ibs./ft. � in.to 3(Ei;�
I.rE'G�� C�n��ruet�.�n in.to ft. Ibs./ft. �n.to-�R.
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft.
�Q�4V V�K111� yrive, .S�a�r�' I,O� SCREEN OPENHOLE
Eden :�rairie, i�N 553�4 Make a �� from n�o h.
Type Diam.
SIoUGauze Length
Set between �54 ft.and 1�� ft. FITTINGS:
STATIC Wij,,,T�t LEVEL _��5r ,
WELL OWNER'S NAME J� ft. L1'Delow ❑ above land surface Date measured
PUMPING LEVEL(below land surface) . r,
Well owner's mailing address if different than property owner's address indicated above. �� ft. after S hrs.pumping �v g.p.m.
�LLHEADCOMPLETION ��lt@Wa�L�r S'�J��!
Pitless adapter manufacturer Model
❑ Casing Protection ❑ 72 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Wellgrouted? �Yes ❑ No �
HARDNESS OF Grout Material ❑ Neat cemeru. Bento ' ❑ Concrete ❑l�i Solids Bento t
GEOLOGICAL MATERIALS COLOR MATEfIIAL FROM TO �� � �
from to ft. ❑ yds. �bags
o � from to ft. ❑ yds. ❑ bags
r�anaY clay i�rvw�n ��ra.
from to ft. ❑ yds. ❑ bags ..
� � �4 12,� NEARESTKNOW`�NISOURCEOFCONTAMIN ATION
�a�ai3 �la� blu� m�d. t! t1�tLlt �3€�f�f�.r j�3.�3i�
feet direction pe
Well disinfected upon completion? O`�7es ❑ No
sac�c�y cla� r�ci �a�d. 1"l" 3� '
PUMP
� �.�t3a��@ ❑ Notinstalled Dateinstalled J" �/��
ciay ar�;� sar�a
k�321�� CUElru�' �.5 1� Manufacwrer'sname
Model number HP Volts
Length of drop pipe_ �20 ft. Capacity �� g.p.m.
Type: LJ'Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS y �
Does property have any not in use and not sealed well(s)? ❑ Yes ❑'IOo .
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes ❑No
WELL CONTRACTOR CERTIFICATION
Use a second sheet,if 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.
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Licensee S3ysiness Name �` Lic.or Reg.No.
r'�--�'K.�"� ."`;-�l��-� ���I �' �
Authorized Representative Signature Da e
xobart �:. Stoa.ola. Jr. 5/8/�U
Name of Driller Date
LOCAL COPY 6 2�. 5 5 8 HE-01205-06(Rev.9/97)