HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD 6 215 7 4
���p���i� Minnesota Statutes Chapter 103/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
Orona 128 23 32 5�,�. 3� id�i,, 136 " 8/7�t3G
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
-c ❑ Cable Tool �C1.priven ❑ Du
�b84 J�4obs i�i111 Rtt O7C4AC7� -):3�6 ❑ Auger o�ocary ❑ Jett d
Show exact location of well in section grid with"X". Sketch map of well location. ❑
�/{\ . Showing property lines,
J roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES O
N
i i � � -��- FROM ft.to ft.
__ _i_ i i
USE � ❑ Monitoring ❑ Heating/Cooling
i i i i O�iiDomestic
❑ Community PWS ❑ Indust /Commercial
i � � i y ❑ Irrigation ❑ Noncommunit PWS ry
w E� �� ❑ Test Well Y ❑ Remedial
� i i � ❑ Dewatering ❑
i i _r i �/ZM.1e . CASING Drive Shoe? ❑ Yes No HOLE DIAM.
_i i _i_ _i_ � ❑ Steel ❑ Threaded ❑ Welded
i -i- i i
Plastic ❑
S
�i Mile-�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME __�in.to 2 3b n. 2i�C� 117.�Ibs./n. $ �.�.
in.to g
+�+`� ����� in.to ft. IbsJft. �in.to 1 3�R,
Property owner's mailing address if different than well location address indicated above. — in.to ft. Ibs./R. in.to ft.
C�� Lecy Con�struetioa SCREEN������,, �. OPENHOLE
1��4� Yfkin<,� Dr .�9t.� .�.�.! Make Cyj� ;�vV' from ft.to ft.
�'l'�@17 Prasrie, �� ��J��#4 Type Diam.
SIoUGauze Length
set between Z��9 ft.and j.3E1 ft. FITTINGS:
STATIC WATER LEVEL y
WELL OWNER'S NAME � _ `,`'"� �$ ft. C?�below O above land surface Date measured $�����
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than pr'opetty etlGnBas a�4r�,s�indicated above. $a ft. after 3 hrs.pumping 3�'} g.p.m.
� ''�f�l
t-���:-- WyF��LHEADCOMPLETION �hit��a�ter .y����
` '��.- - �'Pitless adapter manufacturer Model
�''!, ❑ Casing Protection ❑ 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMAj�QN
Well grouted? Q;'es ❑ No y
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete C�'High Solids Bentonite
MATERIAL
from_�_�to�ft. '� ❑ yds. ❑''�bags
from to ft. ❑ yds. ❑ bags
Cla 17111 Br�W�i St�f CJ 3 from co n. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
�lV� .�Q�1 �1��•,4� .��.�� .] '] �� feet ��+' ___direction 'S�`IT1�� "�7i��
Well disinfected upon completion? C�Yes ❑ No
.7C1flCIy C�3�i BZO�II�I 1��� 7 4� PUMP
❑ Notinstalled Dateinstalled ����vV
a�fl�,� ���,Y b��� ��a �'� �� Manufacturer'sname ���i��
Modelnumber 2�GSZU HP 2 vonits �J�
Li�rc�t'�ir�l. � i'Jt�Cl:a` �.�.X ����� �� �'� Lengthofdroppipe I'Zv ft. Capacity 3v g.p.m.
��� �y
Type: L3'�6ubmersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
�rav�ei b Cla Mix b�e Coars 1"3" i:38
ABANDONED WELLS y ,
Does property have any not in use and not sealed well(s)? ❑ Yes CYNo
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes ❑�IMo
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,SOURCE OF DATA,etc. The information contained in this report is true to ihe best of my knowledge.
1"tE� �v�l� U�iliin� 2"1276
Licensee Business Name�'"�` Lic.or Reg.No.
i f
�/ � l
/ t f .
v��Authorized Representative Signature Date �
Rot�srt E. Stodola, Jr.
Name of Driller HE 01205-06(Rev.9/97)
LOCAL COPY ��� �� Q-