HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 6 2 7 2 3 7
g�,�$ i� Minnesota Statutes Chapter 103!
� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
tt.
; �rono 118 23 33 ��. ��. �. 178 7 29 9
House Number,Street Name,Ciry,and Zip Code of Well Location or Fice Number DRILLING METHOD
❑ Cable Tool O Driven ❑ Dug
140 Gr sta.l Creek Road ❑ Auger iC] 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
� � � � �rTBtEZ FROM n.ro n.
-� _�- '�- _�- � USE ❑ Monitorin
i i i i 1�Domestic 9 ❑ Heating/Cooling
❑ Community PWS ❑ Indust /Commercial
,: i � i � ❑ Irrigation ❑ Noncommunity PWS ❑ Remed I
� w I I I I E ❑ Environ.Bore Hole ❑ Dewatering ❑
' -, i i ,/2M,�e �� � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
_i_ _ i_ _� _ _i_ � �� ❑ Steel ❑ Threaded ❑ Welded
' ' ' ' Q �4 Plastic I;]G111@
s
�1 Mile-�
CASING DIAMETER WEIGHT 1
PROPERTY OWNER'S NAME 4 in.to 1�3 ft. Ibs./ft. $s in.tot�+5 n.
Pi11ar �DI[I$& in.to ft. Ibs./R �in.to+7$ ft.
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to fl.
��O EBSL La�@ S�I'�@ti SCREE OPEN HOLE
Make � �� from ft.to ft.
�c1 j�Z8�L3� � 55�2 Type �ri Diam.
SIoUGauze $ Length 5
Set between ft.and ft. FITTINGS:� g
STATIC WATER LEVEL
WELL OWNER'S NAME 115 ft.�] below ❑ above land surface Date measured 7I�9�g9
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping 5Q g.p.m. °
WELL HEAD COMPLETION tt�
�I PiTless adapter manufacturer �$s Model `F
❑ Casing Protection jtt 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? L�3 Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement � Bentonite ❑ Concrete ❑ High Solids Bentonite
MATERIAL
trom_�_to_�__ft. _�_ ❑ yds.J�I bags
from to ft. ❑ yds. ❑ bags
Ci�` Ye11ow 0 30 from co n. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION t�,I�:���J �4
C1a �_,� 7� feet direction type
Well disinfected upon completion? � Yes ❑ No
�
�rav���Sand A4ixed 4 9fl Pu"'P g��5/gg �
❑ Not installed Date installed
Gravel Cl�' ti1C Q I1Q Manufacturer'sname '�'4'�4r�
Model number HP 1 Volts
�+�3 {Tr6.' 1� 1�4 Length of drop pipe 14Q ft. Capacity 1? g.p.m.
Type: Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
Sand Gravel ��.eCP_Ci J� j � qgqNDONEDWELLS
Does property have any not in use and not sealed well(s)? ❑ Yes Kl No
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes �`C7 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 tfiis report is true to the best of my knowledge.
Stevena Dr��iitx� & E�Qir+��nt�l Services $655 `
LigPasee Business Name Lic.or Reg.No.
' ,�`�� ' � ..i��'.+._�,�.�i_._..
' . , 7I29/99
Authorized Representative Signature Date
i�a;�d� Johasc+n 7/29/99
Name ol Driller Date
- LOCAL COPY 6�7 2 3 7 HE-01205-06(Rev.7/98)