Well Record - Dated 12-12-15 - Laserfiche WebLink

Home Browse Search

� MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD g,1 �0 0 4 Minnesota Statutes,Chapter 10.?I Towns ip a e Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED fl. '/ r GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHO Latitude Longitude ❑Cable Tool U Driven ❑Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location ❑Other 4565 Ba $1�� R�� OL�OYZO 55359 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. j��r From ft.To ft. .; Showing property lines, �, roads,byAgling�nd direction. USE �� Monitorin H `:' . N �._ � � Domestic ❑ g ❑ eating/Cooling �.. __j____j___ _!__ ___;_ � ' ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ` � ❑Community PWS ❑Irrigation ❑Remedial __�___ ._J..- -_�-- ---.-- �Elevator ❑Dewatering ❑ ' ; w ; ; ; ; E T CASING MATERIAL Drive Shoe? ❑Yes y�*(No HOLE DIAM. - --;-- --�-----F— --%-- �' I �J Steel ❑Threaded ❑Welded ..�� , de �h ��M Plastic ❑ � ------ -------------._ 1 � � � CASING S � Diameter Weight Specifications �---i nniie—� �in.To�,7�ft. Ibs./ft. � in.To�tt. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. IbsJft. ��.'�__in.Td.W ft. �nat j �t�i ��I[�$ ��• in.To ft. Ibs./ft. in.To ft. 1� OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREE�Nt,,�. LLJ�� i�tirit� �1� Make..;ViR�i�'I� From ft. To ft. T�,�, Type�R�lt�PQt$ ;$t�� Diam. s.�Q�Q�T1� t� 553�1 SIoVGauze `M� Length J��./.FI Set between ft.and ft. FITTINGS � ., STATIC WATER L Measured from tL ��T R. Below ❑Above land surface Date measured 2 2'�l J WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) RECEII/ED i�7C� ft.after 3 hrs.pumping 30 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �l � �� Pitless/adaptermanufacturer�►t13.te�$ter Model Casing protection �12 in.above grade r]At-grade ❑Well House ❑Hand Pump /� �� GROUT WFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material 1,pnrnr�3 rakom�To_�Q_ft. � ❑Yds. rja'Bags Matenal__��_�r�r�_�To 1 Qi ft. �Yds. T�]Bags HARDNESS OF Matenal From To ft. ❑Yds. �J Bags ' GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To _Bags NEAREST KNOWN SOURCE OF CONTAMINATION C1.8 bCOW11 1�d�L1t�T V �tl f� � teet `+� direction ~� '+�� type Well disinfected upon completion? Yes ❑Na S�:tiKl CZII nL'A ��.LX?3 �1J ��# PUMP 'L Not installed Date installed 1"'13-16 "raveUsand R1i.X 11Ie�i�) 9� �.�� Manufacturer's name Model Number HP_��_Volts sand bca�m r�di�n 120 155 Length of drop pipe �� ft. Capacity g.p.m , _Y�� r�V�� 3x �� C� �M Type: Submersible ❑LS.Turbine �]Reciprocating ❑Jet ❑ �� Li11L.! A � ��J ABA DONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE Was a variance granted from the MDH for this well? �Yes No TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. � The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Seadois Weil Driilin�; Ca,. inc. 1691 Licensee Business Name Lic.or Reg.No. / s, �F.j'.�� J � ,,,,, � Z�2."`l� � . ., etd epr� ntative Signature Certified Rep.No. Date 818 0 0 4 Ro� st«to�a L�C./-�L C�PY Name of oriuer — ID#52603 HE-01205-15(Rev.8/13) � �