HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELL AND BORING RECORD 5 9 Y 5 4 3
11�11118 lA Minnesota Statutes Chapter 103/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
Orc�no 118 "l3 %� �i ,�E,,.SW ,. ��E3 " b/1"l/�8
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
c- C7 Cable Tool ❑ Driven ❑ Dug
�UCI Hui,ter Par�s
i7 Auger �] Rotary ❑ Jetled
Show exact loca6on of well in section grid with"X". Sketch map ot well location. ,� _
ShowmgpropertyGnes, ��� -���-� ��- � �
roads and bu�di s. DRILUNG FLUID
" �" �3�ntoni t�
� � � �
-,- -,- -r- -,-
USE ❑ Monitoring ❑ Heating/Cooling
, i i , }�[7 Domestic ❑ Communit PWS
_i_ _�_ _i_ _i_ � ❑ Irrigation Y ❑ Induslry/Commercial
� � � � �'� � - ❑ Noncommuniry PWS ❑ Remedial
w e T � ❑ Test Well
� � � i • ❑ Dewatering ❑
� � i � ,/zIM< ,,,.�, '� CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
_i_ _i_ _i_ _I_ � `��T � � 4'"'��„� r��.. '� ❑ Steel ❑ Threatled — ❑ Welded
�I i ,�,...-.�-.�.�.^� �i Plastic ❑
S �.T....r�r�...�..,.....
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CASING DIAMETEA WEIGHT
PFOPERTY OWNER'S NAME _______�_in.to_�_�tt. Ibs./R. � in.to ��ft.
J ylan� H���S in.to ft. Ibs.ttt. ���,t��ry.
Property owner's mailing address if diHerent than well location address indicated above. in.to ft. IbsJft. in.to ft.
2�� E• LdK$ S C• SCREEN OPEN HOLE
�Fj�2c�ta� j� rj�,s�l Make � ,1,�,_F from ft.to ft.
TYPQ .y� ,j�l:rt�N Diam.
SIoVGauze�_Q_ __.___ Length 1(�/�
Set between Z 1 j3 ft-and 1�� _fl. FITTINGS:
STATIC WATER LEVEL
WELL OWNER'S NAME �7 ft.�below ❑ above land surface Date measured
PUMPING LEVEL(below land surface) 1
Well owner's mailing address if diNerent than property owner's address indicated above. 1�V tt. atter l hrs.pumping J� g.p.m.
WELL HEAD COMPLETION
7�i Pitiessadaptermanutacturer �hltE3t�Td�.@� Mode� `S���y
O Casing Protection ❑ 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? � Yes ❑ No
HARDNESS OF Grout Matenal ❑ Neat cement ❑ eentonite ❑ Concrete ."O High Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
from � to �� tt. 3 ❑ ytls. �bags
from .3� to 1�� ft. ❑ yds. ❑ bags
��}� ��11 r3.�cl�i� S(.7�rr y 3 from to ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
l:,1,d17 YjrV�yrj ���� � i� �L feet Yi�t$� direction$t3iiiSlt�� rype
Well disinfected upon completion? f�Yes O No
ciaf C�y.`tc�� 3���. 1� �L PUMP
C Not installed Date installed 7�l�g�'i
,5�311Q �e �Y'dVCl �X p]�(j. �L C�(j Manufacturer'sname `�La'�KYt�
Model number _ ,�s HP��_ Volts �.3�
Lengih of drop pipe j 4 V tt. Capacity� L(j g.p.m.
"llt ciay yray Si)f� gb LL1 pressureTankCapaciry L�V __.
Type� �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _
<inn ix ,�o�t lti L4t3
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes f�No
VARIANCE
Was a variance qranted from the MDH for this well? ❑ Yes 0.'No
WELL CONTRACTOR CERTIFICATION
Use a second sheet,i/needed This well was tlrilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge.
RES Well Drilliny .�7�76
Lrcensee Business Name Lic.or Reg.No.
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.�/�.",--.+�q/ ! �� .s+"-" � 7 /
Authonzed Representative Signature Date
J tiI�12 Fa 1.�:�
Name ol Driller Date
LOCAL COPY 5 915 4 3 HE-01205-05(Rev.1/95)