HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO.
CountyName WELL RECORD 5 4 8 5� 2
�E'LIT2E.';JII�t Minnesota Statutes Chapter 1031
Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
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C,�rc�a 117 �' G� ,. �. �. 1_•;�9 11-1 t�--��.
Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
L�6,(? ��r R�lI2 �C�1.1 Q�i.�U� �Cl. ❑ Cable Tool ❑ Driven ❑ Dug
❑ Auger � Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑ _
Showing property lines,
ry roads and buildings. DRILLING FLUID
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--�--�- -1 -1- ��L F�r.; .
1 �4-
i � i X ,USE ❑ Heating/Cooling
� a{pomestic ❑ Monitoring
yy i ; i , E ❑ Irrigation ❑ Public ❑ Industry/Commercial
_1_ _1_ __ __ T ❑ Test Well ❑ Dewatering O Remedial _
I � '
�'^1° CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
--�- �- ; -r- j ❑ Steel ❑ Threaded ❑ Welded
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I ��� C�Plastic ❑
� I milr� �.�AJ
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CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME � in.to �3t�n. ibs.in. � ��� ~l`
��:n.
�C.'�i.�G'� t�I��ct �7ri.�1�7 in.to ft. IbsJft. � �`n`t� nr
Mailing address if different than property address indicated above. in.to ft. Ibs./tt. V i�{,to���V�
'$��� �� S��� 6y,��,� SCREEN OPEN HOLE
nca Make�T�s r_� n from ft.to ft.
1'QP•YI �'c711'1� �tt.�::���'i ����
� Type Diam. �
SIoUGauze l � � � Length C`;�
� Set between 1�f: ft.and '1 iA ft. FITTINGS:
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srnricw�r�F}�L€VEL 'iF��_y�
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO t ft. �below ❑ above land surface Date measured
MATERIAL
. PUMPING LEVEL(below land surface)
(�lci� J Lp� t�j(j� ft. after hrs.pumping g.p.m.
WELL HEAD COMPLETION r.a.'
�`�� S (�'�j 1 �S�}C �?Pitless adapter manufacturer T��-���� Model
❑ Casing Protection __ �12 in.above grade
GROUTING INFORMATION
Well grouted? �Yes ❑ No
Grout Material ❑ Neat cement.�Benropjt -
from �' to �'�� ft. � ❑ yds.� bags
from to ft. ❑ yds. ❑ bags
„�,,,., from to tt. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
�
- r�� feet <_. /�..`.� direction -��!���.:L type
Well disinfected upon completion? ❑ Yes ❑ No
PUMP
❑ Not installed Date installed `" `"�''��'
Manufacturer's name ��L'�:1:Y>�C%�
Modelnumber '��(,(j•_�}L; HP �5; _ Volts L_5�i"
length of drop pipe tt. Capacity �?j r g.p.m.
Pressure Tank Capaciry �1c�. � '�"1C�� ��•i�7
Type: � Submersible ❑ L.S.Turbine ❑ Reciprocating C Jet �
ABANDONED WELLS Y
Does property have any not in use and not sealed well(s)? ❑ Yes LT No
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. -
The information contained in this report is true to the best of my knowledge.
Use a second sheet,il needed �� ��� ���� ����7 �.� �.�. l!� l 2
REMARKS,ELEVATION,SOURCE OF DATA,etc. /Licensee Business Name Lic.orReg.No.
//////����///// �"�l' 11—ifi-94
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M AR �J �- A� Author¢ed Representative Signature � Date
1995 P.�. �'��:�i�can i 1-18-9
Name of Oriller Date
LOCAL COPY � 4 8 5 4 2 HE-01205-04(Rev.5/92)