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Home My WebLink Aboutwell info . ► VvELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD 6 2 Z 5 9 6 ��jl��;� Minnesota Statutes Chapter 103! Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. �runc� 1 i 7 c"� 7 �;� �.5;w ,��;:��. 1 i i House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLWG METHOD - ❑ Cable Tool ❑ Driven �� - ❑ Dug 4 ` ' ❑ Auger �Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ � _. Y,�� Showing property lines, f - roads and bwldings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES RNO N :i , , i i . , - FROM e.co n. -,- -;- -,-- -,- �, � USE ❑ Monitonng ❑ Heating/Cooling � � i i ��-j-'-� rpomestic ❑ Communi PWS �Irrigation h' ❑ Industry/Commercial i i � i � O Noncommunity PWS ❑ Remedial w E� ❑ Test Well ❑ Dewatering ❑ i i i i i i i -r +/2M.1e CASING Drive Shoe? ❑ Yes Q-No HOLE DIAM. _i _ i_ _i_ _i_ � ❑ Steel ❑ Threaded aO Welded � � �� .� : �lastic ❑ 5 ~ ___""r-�.—� �1 Mile� "� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME � in.to_}_}_�ft. d'U� 111$./ft. 3�2 in.to#,�. _ , in.to ft. Ibs./ft.b =in.to�_�ft. 1 Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. SCREEN OPEN HOLE Make from ft.to ft. Type � Diam. _ SlotlGauze � Length �t'�� Set between ft.and ft. FITTINGS: STATIC WATER LEVEL � WELL OWNER'S NAME �l ft. C�below ❑ above land surtace Date measured��,� PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. .[�1 ft. after j hrs.pumping ,�.`j g.p.m. WELL HEAD COMPLETION ❑�itless adapter manufacturer �'JZ 1 L t'W!'ci��.0 Model _�^i��ii ❑ Casing Protection ❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? D�es O No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement ❑ Bentonite ❑ Concrete D�High So�ids eentonite MATEf11AL from i 1'lilto�_ft. _�.�_ ❑ yds. E�bags from to ft. ❑ yds. ❑ bags tsd's1G�Y C:lz'tl� �rUi�11r1 ai-F.''C� � ��7t from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION s��lQ� Lla� ulu-,t�.s {��;�su j� �j�y �}� feet t1UY't,[i direction�y.�W��' :��m� Well disinfected upon completion? �Yes ❑ No �ax�tiy �`�.�'� jCIX�{ �@C��X� � V 11 PUMP ❑ Not installed Date installed j�1 v/ �j Manufacturer's name ��,� iC�j'„� � Modeln�� `I'WC� �1Z@ HP�.�� Volts �],;,y Length of drop pipe �('i ft. Capacity �� g.p.m. Type: �Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS � Does property have any not in use and not sealed well(s)? ❑ Yes �No . VARIANCE Was a variance granted from the MDH for this well? �,Yes ❑ No WELL CONTRACTOR CERTIFICATION Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to the best of my knowledge. �t�5 .v�li i�rllli�g �717a � Licensee Business Name Lic.or Reg.No. t�. J . -- � . '%� ._,._,, �' , '�l�--- �-. Authorized Repr�e Signature � Date'+ Name ol Driller Date LOCALCOPY ��1 �96 `,. - : �-�_, _ HE-01205-06(Rev.9/97) . MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring A ��A � ELL OR BORING LOCATION .__ S@ellfl9 NO. �I H 1 � Counry Name WELL AND BORING SEALING RECORD M;��esota u��q�e we��No. �------- � —�--� IJ j Mmnesota Statutes.Chapter 1031 or W-series No. � I Api.�pQ�l� 0.aev.dwcnnakrownl i _ __. ._ �J Township Name Township No j Fange No Section No. FracUon(sm.-s Ig.) Date Sealed Date Well or Bonng Consiruaed x r 7 ,. ,. lrl�/oi �u.�x� Numencal Street Address or Fire Number and City of Well or Boring Locauon �a�� 2�� igb�o�d �� r �Before Sealing S� _H. Onginal Depth_ ��_.____n Show exact location o�N�ell or boring Sketch map of welt or bonng AOUIFEH(S) STATIC WATER LEVEL in section grid with"X". „ / location, showing property Single Aywter ❑ Multiaquiter �f� � lines,roads,and bwldings. N �AwwV WELUBORING Measured ❑ Estimated jn f7-Waler Suppiy Well ❑MONt.Well "• ❑ Env.Bore Hole ❑Other �tl�fl. .a]below ❑ above land surtace W --�- - -- - -- --i-' E CASING TYPE(S) ' � ' � --�- -i-- -i-- --�-- � Steel � Plastic �Tile �Other ylmile --�- -�-- -�-- --i-- � _ CASING(S) . Diameter Depth Set in overs¢e hole? Annular space initially grouted? S �t mi�e� � in.from� to�_ fl. ❑ �es �No ❑ Yes ❑No ❑ Unknown PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown Property owner's mailing address if dlife�ent than well loca6on address indicated above. in.from to k. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown SCREEWOPEN HOLE Screen fron�y�to_�.� ft. Open Hole from to tt. OBSTRUCTIONS WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑No Obstruction Well owners meiiing a0dress if difierent than property owner's addiess indicatad above. Type of Obstructions(Describe) pa pS ��d „�� Obstructions removed? $� Yes ❑ No Describe PUMP TYPe,�$� GEOLOOICAL MATERIAL COLOR HARDNESS OF FROM TO Aemoved ❑ Not Present ❑ Other FORMATION If rat krawn,iMicate estimated formatbn log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists Dr i f t ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal in.from to R. ❑ PeAorated ❑ Removed in.from to ft. ❑ PeAorated ❑ Removed Type ot peAoraror ❑ Omer GROUTING MATERIAL(Sj (One bag of cement=94 Ibs.,one bag of bentonite=SO lbs.) Grouting Material �.�,.�— from _s�.,� !o_ _fL__._ N. yards _,�___ bags __ from to ft. yards bags from ro fl. yards begs from to__ fl. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property7 ❑Yes x]No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION E This wel!or boong was sealac!�o a�ocrd2nce with Minnesota Rules,Chapter 4725. The information contained in this raoort is � � true to the best of my knowledge. — 8ES We�l Driilit�g 27276 Gontracror Business Name License or Registrefion!':�. ,��. I1 1��: �- ��- c.� 1 . Aufhonzed Representafive Signatu Dafe � �ames Lea - _ LOCAL COPY u��/� Name ol Person Sealing Well orBonng " �� r� �