HomeMy WebLinkAboutwell info '��i��� MINNESOTA UNIQUE WELL NO.
WELL LOCATION � MINNESOTA DEPARTMENT OF HEALTH
Counry Name q � ?O�NELL AND BORING RECORD 6 4 2 9 7 4
H e n n e i n �`�`` ` , � Minnesota Statutes Chapter f031
Township Name Township No. Range No. Sectiort-N&J� raction WELL DEPTH(completed) Date Work Completed
(h'otto 118 23�� Y 33 ,�, �, �i, 161 n 04 27 OQ
�� House Number.Street Name,Ciry,and Zip Code of Well Location or Fire Number DRILLING METHOD
2700 Co erview Lane Orono MNSS 23 � Cable Tool ❑ Driven ❑ Dug
PP s s ❑ Auger �Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map ot well location. ❑
Showing property lines,
roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO
N Water
i i � � FROM tt.to ft.
_� _�_ _i_ _i_
USE ❑ Monitoring ❑ Hea[ing/Cooling
i � � i 1�Domestic ❑ Communit PWS
_i_ _�_ _a_ _i_ O Irrigation y ❑ industry/Commercial
i i i � ❑ Noncommunity PWS ❑ Remedial
w e ❑ Environ.Bore Hole
i i i � ❑ Dewatering ❑
i i i -r ��'M_a CASING Drive Shoe? ❑ Yes �No HOLE DIAM.
_i i _L_ _i_ I ❑ Steel ❑ Thr/e�a�ded ❑ Welded
' ' ' ' 1 QS.Plastic (� "�tied
S
f-1 Mile--i
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME � in.to 156 tt. Ibs./ft. 1�n4to�S n.
Pillar Aome� ��.lo h. �bs.�nb �4�,.�0161n.
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft.
125 Lake Street �1. SCREEN OPEN HOLE
�ITB�ZStB� MN 55391 Make ��C-��_ from ft.to ft.
Type ��.' Diam. �e
Slot/Gauze Length J�
Set between� ft.and 1 tt. FITTINGS: dC @T
STATIC�(ATEfi LEVEL /
WELL OWNER'S NAME 13" ft. f�below ❑ above land surface Date measured ���271�
Pillar �O'9ieS PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. fl. after hrs.pumping 25 g.p.m.
WELL HEAD COMPLETION t,p
�Pitless adapter manufacturer �88 Model `�
❑ Casing Protection '�12 in.above grade
❑ Ahgrade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Wellgrouted? [,��Yes ❑ No
HARDNESS OF Grout Material ❑ Neat cement Bentonite ❑ Concrete ❑ High Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from 6 �to �15 ft. 3 ❑ yds. L�J+bags
from to ft. ❑ yds. ❑ bags
Clay ellow 0 39 from co n. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION OWIl
Ci�.�3t Gray 39 1�5 feet direction type
Well disinfected upon completion? ❑ Yes ❑ No
Clay & Sand Graq 105 120 PUMP
❑ Notinstalled Oateinstalled 5/3/00
Fine Sand Gray 12� 130 nnanufacturer's name Myers
L Model number HP 1 Volts
Gravel � Clay Red 130 IS`� Length of drop pipe I�S ft. Capacity 14 g.p.m.
Sand b Gravel Dark 15�1 161 Type: �'Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)7 ❑ Yes �No
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes jQ No TNk
WELL CONTRACTOR CERTIFICATION
Use a second sheet,i/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.
Stevena Drilling � Env. Services 86654
Licensee Business Name Lic.or Reg.No.
\_
Authorized Representative Signafure Date
Randy Johneon 04/27/QO
Name ol Driller Date
LOCAL COPY 6 4 2 9 7 4 HE-01205-07(Rev.2/99)