HomeMy WebLinkAboutwll info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name ) f WELL RECORD �- ,.� � ,a 4 �
T"t t'tn � Minnesota Statutes Chapter 1031 `--� �- �-
Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(oompl�ted) Date Wock Completed
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Numerical Street Address and City of Well Location . or Fire Number DRILLING METHOD
- 1'�J �i.;� (. � " l �� V �� ❑ Cable Tool ❑ Driven ❑ Dug
�f ' �- S � ❑ Auger [T.Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
ry roads and buildings. DRILLING FLUID
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i � � i �� ,USE �mestic ❑ Monitoring '� Heating/Cooling
`t- ❑ Industry/Commercial
�y �' � i � E {� -" ❑ Irrigation ❑ Public ❑ Remedial
_1_ _�_ _,_ __ T 2, � { ���, ❑ Test Well ❑ Dewatering �
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,,.. 2�mi. '+� ` CASING Drive Shoe? ❑ Yes �No HOLE DIAM.
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--;— i— — —r- , i^ �` � ❑ Steel ❑ Threaded ❑ Welded
''-� �Rlastic ❑
�1 mile�
� CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME �j !t{t�
l in.to fl. Ibs./ft. �in.to .3�.ft.
i � .✓�. �••! �; ., '. t/�'r�. `� t,. in.to�* ft. Ibs./ft. �in.to�
W n.
Mailing address if different than property address indicated above. in.to T ft. Ibs./ft. in.to ft.
SCREEN OPEN HOLE
�. - � Make �(;y�l� •� �� �" from .to�_ft.
•"�� 4 ��_ � .
_ Type "i Diam. a
SIoUGauze 1 � Length t��
Setbetween � �"+L'� ft.and 1����� ft. FITTINGS: ��7`��i ��
HARDNESS OF STATIC WATER LEVEL _
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ;�'� ft.�be�ow ❑ above land surface Date measured � `" E .�
PUMPING LEVEL(below land surface)
�_. '���) ��l�' V\ �/`^.. �.� � ` � i.'�' ft. after a.. hrs.pumping ��_g.p.m.
WELL HEAD COMPLETION �1 '� /
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❑ Casing Protection �9„12 in.above grade
�„f•�,.,�� z�� r �",v�� � c_..,� ,� �f �l�j GROUTING INFORMATION
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Well grouted? �Yes ❑ No
Grout Material �Neat cement �+Bentonite �_.
from�`to ft. + � yds. ❑ bags
from to ft. ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
� NEAREST KNOWN SOURCE OF CONTAMINATION
_-�' feet �—' direction � L' rype
Well disinfected upon completion? �Yes ❑ No j -� '�'�*�
PUMP \ G
+ ❑ Not installed Date installed K — i-�
V F Manufacturer's name �`��c ' !"f G
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Model number HP � �- Volts ✓ ���
� 2 2 199 Length of drop pipe �%� ft Capacity ; �. g.p.m.
Pressure Tank Capacity ���� �- �` f 1 i� i,
O O Type: f�ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
OF �R
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes �,No
� WE�L CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to ihe best of my knowledge.
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Use a second sheet,il needed ����+� . �+!` i._: � . „�„- .�
REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name Lic.or Reg.No.
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1 � � Authori d Representative Signature Date
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Name of Driller Date
LOCAL COPY 5 2 5 2 4 � HE-01205-04(Rev.S/92)