HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 6 4 2 9 7 5 -
Aennepin Minnesota Statutes Chapfer f031
Township Name Township No. Range No. Section No. Fr ction WELL DEPTH(completed) Date Work Completed °"1
Orono i18 23 33 " '��
�((f,.a -�(,f,� 2121 04/15/00 ` ; �
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Du �' �
_ 195 Crysta2 Creek, Orono MN 55323 �Rotary ❑ � �'� �' � �
�
❑ Auger �t
Show exact location of well in section grid with"X". �!'�ltSketch map of well location. ❑ �' J
� Showing property lines.
roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? �� ES � O
N " �
, , , , . Water FROM n.�o � n.
-� -�- -�- -�_ l�o i+ USE ❑ Monitorin
i i i � �� � �omestic 9 ❑ Heating/Coolin
_i_ �_ _�_ __ � ❑ Community PWS ❑ Industry/Commercial
i i i ❑ Irrigation ❑ Noncommuni PWS
y,r E T ❑ Environ.Bore Hole Ty ❑ Remedial
� � i � ❑ Dewatering ❑
i i i -� ,2IM e CASING Drive Shoe? ❑ Yes o HOLE DIAM.
� i_ _L_ _i_ I ❑ Steel ❑ T readed O Welded
� � � � 1 [�(Plastic C��luea
S
�-1 Mile—�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME �1 ;,, �0 116 ft. Ibs./n. 1�„�to 45h,
Pi11aZ HomeB m.to n. ibs.in. 1/,{�0 121tt.
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft.
SCREEN OPEN HOLE
125 take S[reet W Make $yC� trom ft.to ft.
W831ZSt$� MN 55391 Type PVC Diam.
Sbt/Gauze Length 5�
set between 1 I5 ft.and I21 ft. FITTING�s�
STATIC�TER LEVEL �►�1 S�OO
WELL OWNER'S NAME ft.�below ❑ above land surtace Date measured
Pillax HO�S PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping �0 g.p.m.
WELL HEAD COMPLETION
❑ Pitless adapter manufacturer �188 Model �►*�
❑ Casing Protection �12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? �Yes ❑ No
HARDNESS OF Grout Material ❑ Neat cemef,�( [�RBentoryt� ❑ Concrete ❑3igh Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO U 4
from to ft. ❑ yds.�,bags
from to fl. ❑ yds. ❑ bags
Clt�y Yellow 0 13 from co e. ❑ YaS. ❑ bags
NEAREST KNOWN SOUFiCE OF CONTAMINATION �
Clay b Sand Gray 13 35 feet direction rype
Well disinfected upon completion? �Yes ❑ No
Ci1Sy Gray �S 7� PUMP
❑ Notinstalled Dateinstalled 4/15/00
�'.18y � aS8IIt1 Gray 9� 1�0 Manufacturers name ��r
A Model number HP 1 Volts
n Sand & Gravel V='Sp 10� i Z 1 Length of drop pipe Q k. Capacity 12 g.p.m.
Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Ves (�No
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes �No TNfY
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 con[ained in this report is true to the best of my knowledge.
Stevens Drilling 6 Enn. Services 86654
Licensee Business Name Lic.or Reg.No.
� "^- .
Authorized Representative Signature Date
Randy Johnson Q4/15/00
6 4 2 9 7 5 Name ol Driller Date
LOCAL COPY HE-01205-07(Rev.2/99)