HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 612 6 5 4
i�B�lliB�lfl Minnesota Statutes Chapter 103!
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(comple[ed) Date Work Completed
fl.
:���no 11�i 23 33 ,�. �. �. 225 7i�41��
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD �
74t3 Go13�n View �L�.V� QY"(jt1 ❑ CableTool ❑ Driven ❑ Dug
• ❑ Auger ❑�{otary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
f', roads and buildings. DRILLING FLUID WELL HYDROFRACTURED7 ❑YES C�NO
" ��.C'=C_ �! „/'"_ riat�r
, , , , FROM n.�o n.
-,- -;- -;- -,-
USE ❑ Monitoring ❑ Heating/Cooling
i � � i _ tp.� ❑]Qomestic
_i_ _� � � ..� ❑ Communiry PWS ❑ Industry/Commercial
i i i ❑ Irrigation ❑ Noncommunit PWS
w E ❑ Test Well y ❑ Remedial
i i i i ` ��+.�'_ , { ❑ Dewatering ❑ f
-r -�- -r- -r � . l �'1'�i.!'�4� '�:
i i i i CASING Drive Shoe? ❑ Yes ❑f�o HOLE DIAM.
VzM�ie f� i
_� i _i_ _i_ � ❑ Steel ❑ Threaded ❑ Welded
i - i- i i
❑�lastic � 1 ,�,��
s --qz'-cr
�1 Mile�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME � in.to_��_ft. Ibs./ft. _�_¢in.to�ft.
l"
t.L3����G��I�'LY.Z� £Y�(,'1G:�I{ in.to ft. Ibs./ft. in.to ft.
Property owner's mailing address if different than well location address indicated above. in.to ft. � Ibs./ft. in.to ft.
���J +�IO�Ct� �.L S�a�i'��� Lt�Tlt�. SCREEN OPEN HOLE
��y��{�u��jt L'� ����� Make - from ft.to ft.
Type 1rV Diam. -.
Slot/Gauze � � Length �l
Set between �'7 n ft.and_��_ft. FITTINGS:
STATIC WATER LEVEL ,
WELL OWNER'S NAME �l�► tt. I]K below ❑ above land surface Date measured]�Q��
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping �� g.p.m.
WELL HEAD COMPLETION
� Pitless adapter manufacturer �`��..��$ Model ���
❑ Casing Protection ❑�2 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? C�,i'es ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material 6�leat cement ❑ Bentonite ❑ Concrete ❑ High So�ids eentonite
MATERIAL from c3 to__,_�_�_ft. �?C1 ❑ yds. ��ags
from to ft. ❑ yds. ❑ bags
::iay y,�ilc�;ri �,3 1 from co n. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
��o� ���y� �� �i feet direction � type
Well disinfected upon completion? ❑ Yes ❑ No
V�Gi� �Y �i�V�L :3ttU� .�6.t l? PUMP ��*�n�
❑ Not installed Date installed � j
'.sZ'i3Vt��. iBj.X'�':i �7,� c� Manufacturer'sname °"�]' `t-'r�
Model number HP � Volts
i.�.�� � j r;�v�� �`r�` �7 1� Length of drop pipe 1�� ft. Capacity 1'�� g.p.m.
7 �1 Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ila {�c �ro��7�'1 .��� f ��+ � � ABANDONED WELLS ,
Does property have any not in use and not sealed well(s)? ❑ Yes Ri.No
�anc� & ravel rz 1 �5 �2 �
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes ❑�io
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,SOUFjrE OF DATA,etc. The information contained in this report is true to the best of my knowledge.
Steven� �rillin & E -. II�,�54
. �� � � ���� " License4 Business Name � F Lic.or Reg.No. �
4` !
� � f� `i+>,,,�„��'"��'r� �
4 i�-� �•. .S i '�'.,, . � e
''' Authorized Represenl8tive S�gnafure Date
..,i S � _. �a�Y�a���
�artdy �t,7Joh.��r�n
Name olDriller HE 01205-06(Rev.9/97)
LOCAL COPY �'j�.�� �j �