HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 612 7 4 4 �
ki4�'+a;��?a.�'; Minnesota Statutes Chapter f03/
� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
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t�,•{7:,� 118 �3 33 �,. �,. ,, 1:34 i�/3(3iQ�
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
���' �i�'.'^.'Ci''., ?"' ❑ CableTool ❑ Driven � �,` 'Dug
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� 7. f.i'<<�-�:� �?"il`"lt� ❑ Auger C�:Rotary:.,,, . ❑ Jetted ✓
Show exact location of well in section grid with"X". � Sketch map of well location. ❑
! owing property lines, �
��p��. L/A_��roads and buildmgs. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO
N ��t
� i i i '":�t��� FROM ft.to ft.
-� -i- -i- -i-
USE �. ❑ Monitoring ❑ Heating/Cooling
i i i i �-Domestic
_i_ _�_ _� i ❑ Community PWS ❑ Industry/Commercial
i i � i t ❑ Irrigation ❑ Noncommunit PWS
w E �"`_^ ❑ Test Well Y ❑ Remedial
i i i i ti. .�{.� ❑ Dewatering ❑
T } l/
� � _r -r y2M.ia ��C.�tE' � ` '�s��� f CASWG DriveShoe? ❑ Yes ptNo HOLEDIAM.
_i i _i_ _i_ � � (E Y�Y" ❑ Steel ❑ Threaded ❑ Welded
i -i- i � {�
S d Plastic ❑
�-1 Mile-� �
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME 1} I Z7 S� �i5
in.to ft. Ibs./ft. in.to ((�t
�i��.:r l" �7��� in.to ft. Ibs./ft. �in.to��R.
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./R. in.to R. .
!�iQ �%4.^v~ I.���Cd� .,'rS�.T�?r?t� SCREEN OPENHOLE
''••T- t 14�� ���t3� Make ����t� from_ ft.to fl.
n.,:•,�,•.�' 9 . �
Type Diam.
SIoUGauz�� r�, Length
setbetween �.�� ft.and�n. FITTINGS: � ��CIC.
STATIC WATER LEVEL
WELL OWNER'S NAME 7�f R. ❑:Ybelow ❑ above land surtace Date measured lZ 3� �}�
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping 50 g.p.m,
WEL�HEAD COMPLETION ���r j ta
C3�Pitless adapter manufacturer �1` `' $ _ Model }
❑ Casing Protection _ d..'C12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? OFYes ❑ No
HARDNESS OF Grout Material ❑ Neat cement a''8entonite ❑ Concrete ❑ Hi h Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 9
from �_to 45 rc. 3 ❑ yds. o-^bags
from to ft. ❑ yds. ❑ bags
(;j.�' YE�.s'..UW 0 4Q from to ft. ❑ yds. O bags
NEAREST KNOWN SOURCE OF CONTAMINATION A�praF.
{'iTAV2�.� �i21 �I'E'y t}(} 60 feet �r _direction type
Well disinfected upon completion? L1Yes ❑ Na
Si3Tt{�IGI�3VC�. .�sCE3y VE'1 �G PUMP
❑ Not installed Date installed �/1�/��
Cl�ttpj S,��-.�. Grey *,�..
� �� �' Manufacturer's name '��� '
C Model number HP � Volts
s�t�� Gr��' 1{�J 13� Len th of dro �"�� �-",
g p pipe ft. Capacity g.p.m.
Type: C�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
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ABANDONED WELLS ,
Does property have any not in use and not sealed well(s)? ❑ Yes Cf3 No
VARIANCE
Was a variance granted From the MDH for this well? 0�les ❑�No
WELL CONTRACTOR CERTIFICATION
Use a second sheeG 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.
S.�-N�����; �*-:�'.'�.��� & �:��r. Sexv�.6,F>> �6654
. . � Licensee Business Name Lic.or Reg.No.
, Authorized Representative Signature Date
" R<�t,:d;� J81ir.y':�n
Name of Driller Date
LOCAL COPY 6�2 7 4 4 HE-01205-06(Rev.9/97)