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Home My WebLink Aboutwell info�_ WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD 612 7 0 5 - ��ij��, �a Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. ��@ II� 23 33 '�'��. SFti f��1�. 15� 12�28 98 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 170 CZ E3�F3.�. CTr..fx ❑ CableTool ❑ Driven ❑ Dug k Ao3d ❑ Auger Cl�Rotary _ O 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 O N � � � � h$?2�'t3��.t� FROM n.co n. I I I I �� USE ❑ Monitoring ❑ Heating/Cooling i i i i ^�K.�,„ �Domestic ❑ Communit PWS `�„ Y ❑ Industry/Commercial � -� i i � ❑ Irrigation ❑ NoncommunityPWS ❑ Remedial w e ❑ Test Well � � i i (.{ ❑ Dewatering ❑ i i i i ��ZM_a � CASING Drive Shoe? ❑ Yes o HOLE DIAM. i i _i_ _i_ ��// ❑ Steel ❑ Threaded ❑ Welded -i -i- i i 1 � L�Plastic � i1..�11� _ �1 Mile� � CASIN DIAMETER WEIGHT PROPERTY OWNER'S NAME `" � in.ro �� ft. Ibs./R. �� in.to4�5+�ft �i�.l'd�X xaDlG� in.to tt. IbsJft. ��; in.to 1-�'-ft. Property owner's mailing address if different than well location address indicated above. in.to ft. _Ibs./ft. in.to ft. 7�V E89� Lt�k6 StrE@t � � � �� SCREEN OPEN HOLE Make �<?�CL� from ft.to ft. � 11Pe�T:i.i:1L'8! �;iv 5539� �;I.��S �(, � ��',' ` Type_ �1G Diam. .T �► 1� �ength �� SIoUGauze .�, Setbetween 1G7�-15t�ia�d I5�^ ft. FITTINGS: K--parker �;,��t v r-��;r�r��,�d: STATIC WATER IEVEL WELL OWNER'S NAME �� ft. �below ❑ above land surtace Date measured '�"��f PUMPING LEVEL(below land aurface) n Well owner's mailing address if different than property ownePs address indicated above. ft. after �/� hrs.pumping �� g.p.m. WELL HEAD COMPLETION �Pitlessadaptermanufacturer �38P3 Model �1�� ❑ Casing Protection _❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �'es ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material P�eat cement �entonite ❑ Concrete ❑ High Solids Bentonite MATERIAL from � to �F�J ft. 3 ❑ yds. � bags from to ft. ❑ yds. ❑ bags �;f.'i,7 Ytx1�.G'iQ � 3� from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION �� z3,,' Gray 3{� Ets feet direction _type - Well disinfected upon completion? C9Xes ❑ No /�. Gr�vel �iXP.(� Fi� ��} PUMP ❑ Not installed Date installed !!�!V� Gravel/CJ.�.y ��q �� Manufacturer'sname ��fi Model number HP � Volts C1a1r t�r�.;; 145 I3f? 12f1 15 Length of drop pipe ft. Capacity g.p.m. Type: C�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ '' r..•��-;�?./Ss;.-.z,a ��i.x��cx' I30 152 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 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. St�verz^ '��I.l t.-iri� & En��. Sera�ir�s �r36F�54 Licensee Business Name Lic.or Reg.No. _ _ .___ 21�0/�� Authorized Representative Signature ��- Date Ratnc�=� J�h*�son ,�+ r Name ol Dnller �� Date LOCAL COPY 'LJ �2 7� �O HE-01205-06(Rev.9/97)