HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 6 2 7 2 3 6
Henne in Minnesota Statutes Chapter 103/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH�completed) Date Work Completed -
ft.
Orotzo 118 23 33 ��. ,, ,. �61 7/2�/99
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Dug
60 Cr s�t1 Creek Rogd ❑ 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
i i i i � Wr�t$r FROM ft.to fl.
-i -i- -i- -�- ,..,,���-
� � ���. USE ❑ Monitoring ❑ Heating/Cooling
i i � � r� Domestic ❑ Communit PWS
—�— —J— —�— —�— e��! F-.' �-t�' �Irrigation Y ❑ Industry/Commercial
i i i i ;q,...� ❑ Noncommunity PWS ❑ Remedial
y� E T b*� S, � ❑ Environ.Bore Hole ❑ Dewatering ❑
-i- -�- -r- -r I \�,,r \ . \�.,...-.
i i i i / , �' �' �� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
- - y2M,_L� � l�l�-
i_ _ i_ _i _ _i ❑ Steel ❑ Threaded ❑ Welded
' ' ' ' �P�astic �.. glue
s
�1 Mile�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME 4 in.to 1�6 ft. Ibs./ft. ��Y�n.to i�ft.
Pillar �01�C2i in.to ft. Ibs./ft. �
�fy���.co�n.
Property owner's mailing address if ditferent than well location address indicated above. in.to ft. Ibs./ft. in.to ft.
7�iO F.r19C LB�SC S�re�'L SCREEN OPEN HOLE
�ilayzata, :�? 55391 Make J��rcn r�om n.co a.
Type �!� Diam.
SIoVGauze Lengih �f
set between n.and 1 b� n. F�rrwGs: �—p$ck
STATIC WATER LEVEL
WELL OWNER'S NAME �-Q� ft.�•below ❑ above land suAace Date measured Y �"�"r C
- PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner s address indicated above. ft. after hrs.pumping �Q g.p.m.
WELL HEAD COMPLETION t.��
❑ Pitlessadaptermanufacturer�gx+t$ Model '¢
� ❑ Casing Protection ❑ 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
a; ' GROUTING INFORMATION
� Well grouted? `Q.Yes ❑ No
s� GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement I$,Bentonite ❑ Concrete ❑ High Solids Bentonite
MATERIAL from d ro �5 tt. 3 ❑ yds. �bags
from to ft. ❑ yds. ❑ bags
Cl�y 'Y'`�'`1'Gw �3 3� from to ft. ❑ yds. ❑ bags
� NEAREST KNOWN SOURCE OF CONTAMINATION �,: ;•;i (ij rM',
Ci�.c3?.' t'iL1y .�Q !� feet direction type
Well disinfected upon completion? '�..Yes ❑ No
CJ_:�v IGr�iV�1 �1c-�..xk GT"•r 7O 10.5 PUMP
J ❑ Not installed Date installed 1 a/�/99
CI�y Grau IC�S I4t', I�q,�ry
Manufacturer's name
Model number HP I Volts
Sand/GruvEl Mi.��� I4� �51
Length of drop pipe 14� ft. Capacity �� g.p.m.
�x,aV��.�L•1c�.J kk?t� 1�2 I�T•t Type:� Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED 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
S
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.
Stenens �rillin�, t4 Env. Servicrs 86654
; .LicQnsee Business Name Lic.or Reg.No.
�`'�i+�P� ;�\� ,� � 1r`, `-=`�.--�--�1.0/25/99
,
Authorized Representative Signature Date
�ndy 3c�hn�ert
Name of Driller Date �
LOCAL COPY 6 2 7 2 3 6 HE-01205-06(Rev.7/98)
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