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HomeMy WebLinkAboutwell info STATE OF MINNESOTA DEPARTMENT OF HEALTH � AT�0.N WATER WELL RECORD MINNESOTA UNlQUE WELL NO. � County Name , ��(j��� /f_,k{y„�-i_ ,._2_._� Minneso(a S(afules 156A.0I,08 /or Wafer Sample `J Township Name� � Township Number Range Number Section No. Fraction 4. WELL DEPTH Immpletedl Date of Completion '_ . � , °' _,.�.r'.E aJ.� � � � �''� / ft. f�' - /Ce �/O Nymedeeh3tieEf=�d8tE55-and•City.t�f.Vl�ell.Lacation or Distance from Road Intersection. 5. DRILLING METHOD J i �{ - J,�� . ❑Cable"lool ❑Reverse p Driven ❑Dug ; <��/ '' !:�._sP r :F'.. � � - ,4+--� . ow exact location ot well in section grid with"X." ��� � ��Ske[ch map of well location. ❑Hollow Kod ❑Air ❑Bored ❑ N ._� � _i _1_ Addition Name �Rotary ❑Jettcd ❑Power�Auger -� � - �'�� --�� � 6.DRILLING FLUID � --�- -=- �_ �_ Block Number �y � � j E 7. USE i _1_ _1_ _'_ _ T �1 Domestic ❑Monitonng ❑Heat Pump I � ' Lot Number ❑Irrigation ❑Public ❑Industry 'f_•mr. ' � � � ❑Test Well {]Municipal ❑Commercial --�- �- - -r' ❑AirCondiuoning ❑ i �—1 mile� 8.CASING HOLE DIAM. 2.PROPERTY OWNER'S NAME Mailing Address if different than property address HEIGHT:A6ove/Below �I Black p,�Threaded indicated above. Surtace (i. : / �� � � _ ! ❑Galv. ❑Welded •�.,. , � ij. ��j/ �} !?�� I�� ,. ;'.:� Drive Shce? Yes�jS,No— , _. • � d '°^�, l.'�i��. � . :'..y,'s.�.. ..- _. . . O Plastic ❑ : ;.�::... �..' , �� _C .,.....-,.._. r= �__!. .� .� � � g ;�.:n � ',d. ��, � /,.� .f.r ,. ''A! in.to -? � (�. Wei ht � � Ibs./(t. �in. t �t. 3. FORMATfON LOG COLOR FORMATIONF FROM TO in.to (t. Weight IbsJtt. �n. to„iE�e�t. in.to (L Weight IbsJft. �n. to—ft. � 9.SCREEN Or�open hole �' ' ,-. .. j F ,. �� � , _ _ .. �. � ....�:... , . �.�� � from�fl.to. ��(l. Make - . � . .�::.-{ . }'.F{i.:.f � � "3 F'.: �f TYPe Dlam. f Slot/Gauu Length FITTWGS: ' -- ,--�:�. f� � �� � Set between tt.and f[. � ��� i � . 3 .�10. STATIC WATER LEVEL f�r-�_ � _ � �� � f ���'�� '� '"r`�f� f L u (t.�below O above Date Measured / l �`at land surface . � - 1l. PUMPING L6VEL(below land sur(ace) r ' : i- r1� td � � ' ti` � �"'"i; ([.a(ter `� hrs.pumping �',�!� g.p.m. (t.a(ter hrs.pumping g.p.m. 12. HEAD WELL COMPLETION .,r. .,.,�,,,,. �1Pillessadapter manufacturer {��'"-'�"�"��"-'"�- Model -J- `/ 'O Basement offset ❑A[least 12"above ground ❑Plastic casing pro[ection 1'3. WELL GROUTED? y,,,xes ❑No � ❑Neat Cement �entonite ❑ . . ._,_ Grout material (rom ��to_.�—ft.cu.yds. 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION � ' ��`� -�-`feet "'"J direction -�<'�x�-�^- r✓�+t'`j' -,_- �YP� �. Well disinfected upon compietion? �Yes ❑No 15. NUMP �.. DE C 1, 7 ,S,t7e�►.�l Date installed � ' � d// �� ❑Not installed Manufacturer's name ���•�'"e..r�.�.�-�+.. d"*7 , ..,E.,.�. Model num6er -3 f � � /L4--� HP_�y Volts��� I.ength of drop pipe ��!j / ft. Capacity ,�•-,fl g.p.m. Material o(drop pipe � .-SC Type:7GLSubmersible� O L.S.Turbine Ll Reciprocating �Jet ❑Centritugal C7 l6. ABAIVDONED WELLS Unused well on property? ❑Yes �'No Use a semnd sheef,if needed � Sealcd ❑ Permanent ❑ Temporary ❑ Not sealed 17. REMARKS,ELEVATION,SOURCE OF DATA,etc. • 18. WATER WELL CONTRACTOR CERTIFICATION This well was drilled under my jurisdiction and this report is vue to Ihe best ot my knowledge and belief. J c� �'e� ..�1� ;.> l � t� a l �' Licensee Business Name, /. L+cerrse No. � Address `j � ✓ �. : 1�;✓� _.� r:%..-n- Signed .�-t . _ .,f�� Da[e` . . . ��.� � Authortzed Representa[lue � -9 !a t %` �'.t `�1—f i.����-5�'"�,..-->. r Date _I f il Name oJDriller LOCAL COPY O�O 61� 5/7430M 7/76 30M HE-01205-03(Rev.9/88) �i�e 3°M ziez�a.n