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Home My WebLink Aboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CounryName WELL RECORD 5 2217 2 �t f ,L,:r „;i ,,y; Minnesota Statutes Chapter f031 Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed c� n � � `��;�rv� l�� j .I �S ��,� �. �" �. U�] / ' � Numerical Street Address and Ciry of Well Location or ire Number DRILLING METHOD � . ❑ Cable Tool ❑ Driven ❑ Dug � !' ` '� ! a- � -% i: !'' "� ❑ Auger {�Rotary ❑Jetted Show exact location of well in section grid with'X". Sketch map of well location. ❑ � / Showing property lines, N ��f roads and buildings. DRILLING FLUID I � � � '.} .-., ...�-r^--. ... --r'—'1— —1 —1— i (� �'�" i_._ - .,r l� i � i ,USE ❑ Heating/Cooling � � �Domestic ❑ Monitoring --+- -',- �- �- ❑ Industry/Commercial yy � , � � E i/t t� 4/ ❑ Irrigation ❑ Public _1_ _s_ __ __ T ❑ Test Well ❑ Dewatering � Remedial � � � � ' h m;. CASING Drive Shoe? ❑ Ves ❑ No HOLE DIAM. --�- �- ; -r- I ❑ Steel ❑ Threaded ❑ Welded � 1 �Plastic ❑ �1 milr—� �,5 l ✓ n/-"S3 jw. � CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME � in.to J u�tt. ,,r� �' `? Ibs./ft. �in.to-��L�ftT. ,_i �: �r , � i l'- r .:� yv, in.to ft. Ibs./ft. !�'n.to� Mailing address if different than propeRy address indicated above. in.to ft. Ibs./ft. in.to ft. ! � G �,f� ,� (,(� jf.�/ �� , SCREEN OPEN HOLE • � .` Make � �' �� from ft.to ft. r / .� vb'`I r.�4� li-� !� f �"�� /C'� �+ �- f/ .)� �'�.. TYPe -� G. Diam. SIoUGauze �,f'� Length .� ` Setbetween ��,2 tt.and�__�_'�ft. FITTINGS:�.�v��j_T_��= STATIC WATER LEVEL GEOLOGICAL MATERIALS COLOR H MATERIAL�F FROM TO ft.�below O above land surface Date measured r,rj �j� � PUMPING LEVEL(below land suAace) j „ �, Y� ! ��,�,.��_� � ,�� t) ft. after � hrs.pumping ,,�� g.p.m. � WELL HEAD COMPLETION e .{� �G � � f/`l:^ J: � � �'( ,; f . , �"� �,� C�Pitless adapter manufacturerLY+s*�..L.. _��iw...-- Model .3-� f �� ,r'� _ ❑ Casing Protection ❑ 12 in.above grade r� � /"�' � � �(j�� GROUTING INFORMATION , .._._:...,/_-'-�, _ , T �.,.tli"+.fi Well grouted? f�Yes ❑ No � �� { � Grout Material t�Neat cement ❑ Bentonite , %��..- �r�.� from .T/1 to��ft. ❑ yds. ❑ bags t- � � � from to fl. ❑ yds. ❑ bags �i • J � 4,�, �y/� �-`„� '/ ! � �� from to ft. ❑ yds. ❑ bags ��,,J� � .. NEAREST KNOWN SOURCE OF CONTAMINATION r�; � ✓ r�✓,� �� s . �t"'J `� _�_3 teet r5.i directior�.-�type ,-. �- ;/ Well disinfected upon completion? �Yes ❑ No PUMP �Not installed Date installed ,,y,_ Manufacturer's name ��./�-s-�•-�-•"�''/ Model number �T! �� HP_��_ Volts..� � (j Length of drop pipe ft. Capaciry ��j g.p.m. Pressuie Tank Capacity � � ,�,,. Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any hot in use and not sealed well(s)? ❑ Yes �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�rue to the best of my knowledge. Use a second sheet if needed �� . � � ��e 1��('-.��,•� ��/ �) / �7 C s / �{.a REMARKS,ELEVATION,SOURCE OF DATA,eta Licensee Business Name/^� Lic.orReg.No. � �'..:� � �� e�. > � �� Authorized Representative Signafure Date L t�('fJ�. ? r�p}� / � ' � J C! �'�1 -f,�jr^ �c''��?vLu-,_. �` , Name ol Driller Date LOCAL COPY 5 2 217 2 HE-01205-04(Rev.S/92) STATE OF MINNESOTA DEPARTMENT OF HEALTH ABANDONED NELL RECORD i. �otATton ov uE�� MINNESOTA UNIQUE WELL N0. � f I County Name .�� (leave blank 1f not known) ;J � � � J I 'ovnship na e Tovnsni Numoer Range Number Section No. Fraction a. WELL OEPTH (completed) Date seated � ry E ; k of , / or / !��i/�i�— l l � Sr � .� W 7 � `r) ft. �� /`//L I li � 4umericai Street Address ane City of Vell location or Distance from Road 5. DRILLING METHOD (if known) I i :ntersection 1�Cablc tool 40 Reverse 7[]Driven 10(�Dug I L/� � / /�,c ��j��T %,' j��i/ 2[]Hol low Rod 5[]Air 8�]Bored 110 c� tv --t�> /• X I Shov eznct location of well 30 Rotary 60 Jetted 90 Dower Auger (in seccion griC vit� "X") Sketch map of well location 6. OBSTRUCTIONS � � / �/ ��'�� Nell obstructed�Yes � No I —� _ � _ _ _ _ � " Obstructions removed�Yes �No If obstructions cannot tre I ' -I ` � removed, con[act MOH � y ' ' 'I" _ ' -�- ` - E before sealing. il ' � � ' i . � . . � _ T I �� 7. USE i ; '( ' S .,,:, i 1}A,�Jomestic 40 Monitoring 8�Heat .00p _ _ , ^'�� I .__._—� 2� Irrigation 5�Public 9� Industry I � � � � 3�Test Well fi0 Municipal lC0 Comnercial i $ : .iL 70 Air Conditioning 11� i ' 2. ?ROPERTY puNEfi'S NAME Mailing Address if different than 8. CASING(S) ; �„Z�,�`,.�,J` proDerty address indifated above 1�Black 40 Threaded 7[] � � � yG U f- ��_ ��- . i 2[�Galv. 50 Melded � � �-�� '7�� J-� 3 `l f— Jr]Plastfc 60 Statnless Steel � � HARDNESS OF I 1n. to � -� ft. j 3. FORMATION LOG COLOR FORMATION FROM TO I I If not known, indicate formation log from new well or nearby well. 1n. to ft. I� I , 9. SCREEN �7 I �Screened well from L J ft, to/ � ft. � ^ r' (If know�) �.+ � V ❑Open Hole from_ ft. to _ ft. � 10. STATI WATER LEVEL � i ft. Q below �above ��• I � { land surface Date Measured �� -� I � � 11. WELLHEAU COMPLETION I I IQ Pltless Adapter CQ Faund Buried ��, � 2�Basemen; offset � i � 30 Well Pit � �16. REMARKS, ELEYATION, SOURCE OF DATA - CASINGS REROYED, CASINGS PEkFORATE�, ETC. i , 12. GROUTiNG INFORlIATION i 1�Neat Cement 2[]Bentonite � ��,� Grout material from�to�ft. cu. yds� — — —� 13. NEAREST SOURCES OF CONTAMINATION � feet �_ dlrectlon •-LL�c�.—. type � , j Mell disinfected before sealing? ,� Yes I 14. PUMP f,7lRemoved � Not 7resent Y Type: 1� Submersible � L.S. Turbine � Reciprocating __,_ _ ---- � ""�`� d�Jet 4�Cenirifugal 60 r- � 3 � I ` � 15. EXISTING WELIS (Ptease sketth locatlons of abandoned and ac:ive wetls in remarks section or on back.) I , _,�_ Other unused well(s) on property? �Yes (�j Na Abandoned: �Permanent �Temporary �Not senled ].7. WATER WELL CONTRACTORS CER7IFICATION � This well Was sealed under my jurisdlction and this report I is [rue to Che best of my knowledge and belief. APR 2 �.9�3 �_' C=J`� �.��1�? ,� 1:; � � Ucensee 9usiness Name License Na. I L �' � , ��-..�', ,� .l. Addre55 �'T�L i�a " -��- �� Signed � � __,._I�'� � Oate /L •( �f�L � ' n _ � `�ft-��,J�-�-� Date i,� �6 Jf �FFICIAI ABAIIDONED �ELL RECORO (May bt used for Property Transfer} �� of Drtller + II�CRTANT: lZLB G7TH DBSD