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Home My WebLink Aboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELL RECORD 5 5 9 6 4 4 Minnesota Stafutes Chapter f031 �zt'. _ Township Name� + Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. ;� ,-- �.�: �ra �� a�,. ��,� s�,��,. ., Numerical Street Address and City of Well Location e or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug � ;�� - - B.].�t%� ❑ Auger ❑ Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ i Showing property lines, N �,'�;'^ = ,.,�, � .. `�-�',�'; roads and buildings. DRILLING FLUID I i � � A - --r--7- -' -1- . .. _. ...') ;`t.-= +"...; ..y i � � ,USE ❑ Heating/Cooling _�_ _�_ �_ �_ CL Domestic ❑ Monitoring ❑ Industry/Commercial yy i � I E ❑ Irrigation ❑ Public _1_ _1_ __ __ T ❑ Test Well ❑ Dewatering O Remedial I ' � ' ' r-mi. CASING Drive Shce? ❑ Yes p No HOLE DIAM. � 1 --�- �- ; -r- I ❑ Steel ❑ Threaded C Welded -� ' ' 1 [,x.Plastic ❑ �—1 milr� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME in.ro _i'�.t.� � IbsJft. �Z in.to-'� ft. i'�. -:�_;. in.to fl. IbsJfl. �in.to.��;_�ft. .._' � Mailing address if different than property address indicated above. in.to fl. . Ibs.ttt. in.to R. SCREEN OPEN HOLE Make . '.�1 i ��1�-� from ft.ro ft. Type . - Diam. ' ,.. SbVGauze � � y��r� Length 'i�l � Set between i�'� tt.and ?r.,� ft. FITTINGS: STATIC WATER LEVEL HARDNESS OF GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ;;Q':' ;r=; ft.��] below ❑ above land surtace Date measured 7 �� PUMPING LEVEL(below land surface) :�:3..::i F �c .` ?•t��;: ��Z rJ:;�C! ..... .:_�i: � : c.� tt. after hrs.pumping `�t� g.p.m. WELL HEAD COMPLETION `..:i_, � ..:�t;).'�;,1 I1 .:,;�3 i ��.. ;.�� „��, ❑':Pitless adapter manufacturer ".i�-�`',��,c� �<;;t�.:'Y Model ', � ��-�L � G Casing Protection ❑ 12 in.above grade Fk L.�_�i; :'Jr�3�7�:� "'O�t ZS �J� GROUTINGINFORMATION Well grouted? CS Yes ❑ No .. � _ _,. .. .- ,.A,; 4:`a��. ��7 y�7 Grout Material ❑ Neat cement IXBentonite �� {� to >� ft. ❑ yds. ❑ bags from from to ft. ❑ yds. ❑ bags � - •-��- � ' d'� ' � � from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION 1 t1 7 1:I;-.=' _``�i feet �i}`+�l.;"_ direction . �,� rype - Well disinfected upon completion9 .O Yes ❑ No '` �" PUMP / ❑ Not installed Date installed _____71 7 T.��!w' Manufacturer's name ,�%`s ill;�L:s L' Model number HP � i -'. Volts ��`� Length of drop pipe ;,Q� ft. Capacity 1� g.p.m. Pressure Tank Capacity_�o u i Type: �.� Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS - Does property have any not in use and not sealed well(s)? ❑ Yes C��No WELL 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 the best of my knowledge. Use a second sheet,il needed ....1'i€��.. ..'�r v i�`.: i.� . t- i� �. .. . REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. f �! � 19�6 _ : ti�A = r H�` ��' ��'`_ N � ��i,� .�.�;-'� a_ - �► �. ��Authorized Representative Signature --j Date rta4r� _ . -. _. ._:+�:... �Y 7J.?_7/9:� Name of Driller Date LOCAL COPY 5 5 9 6 4 4 HE-01205-04(Rev.S/92) Minnesota Well and Boring wELI OR BORiNG LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H �o�� e WELL AND BORING SEALING RECORD M��eso�a u��Q�e No. � Minnesofa Stafutes.Chapter 703/ or W-series No. ILeave blank A nol known� To hip Name ownship No Range No. Section No Fraction(sm. �Ig� Da�e Sealed - Approzimate Date Well � } t-� or Bonng Constructed t IQ t umencal Streel Addre s or ire mber and City ol ell r Bonng oca n ' / � �� Ar./ Deplh Before Seahng ,�--/ it. Onginal Depih ft. Show exa bcahon o well or bonng Sketc map of well or bonng Static Water Level 0 Accurate �n section gnd wAh��X . locatron.showmg property hnes. '� roads.and bwldings. ❑�Approximate N � � i -,- c ., � Smgle Aquifer ❑MulUaqwfer � ' fl. ��`-� below above land suAace i i _�_ _i_ -i_ CASING TYPE W E � � � � i , i i � �Steel ❑Plastic ❑Tile ❑Other mi�e '�' _ �_ _� _ __ •� � . 1 S ' Screen irom �.`, to -- fl. Open Hole from to ft. �""'k� OBSTRUCTION/DEBRIS/FILL ❑Obs�ruction ❑Debns ❑Fill PROPE�T_Y_OWNER'S NAME �.. r ' � Type of debns/obsiruchon Maihng Address d ddferent than propeny address mdicated above. Obstruclion/Debns/Fill removed? ❑Yes ❑No PUMP �Removed ❑Not Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS Of FROM TO FORMATION Diameter Dep�h Set in oversrze hole? Annular space inAially grouted? If nol known.indicate estima�ed brmation log irom nearby well or boring. �� m.irom �_to ��_� fl. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to fl. ❑Yes ❑No ❑Ves ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: [�.No Annular Space Exisis ❑Annular space grouted with tremie pipe ❑Casing Perfora6on/Removal in.from �o ft. ❑Per�orated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of perforator ❑Other GROUTING MATERIAL Grouting material w T! from ��Y to �ft. yards bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to ft yards bags from to fl. yards bags UNSEALED WELLS AND BORINGS Other unsealed well or bonng on property? ❑Yes ❑;No LICENSED OR REGISTERED CONTRACTOR CERTIFICATION JA N 1 0 1996 This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725 The information contained m ihis report is �rue to the t of my kno�dge. ` /, /`�' �,, , fracYel ne _ � License or Repisf �ion o. 7 •'l�J� 1�� .G ' J�. -- .. / Autlionzed n a r gnaWr- ' Date .• ✓/ � � /'� � -;;! ,i' �_. �L��„Sr.;p��'�f' � � Name o!Person!Ea ell� goring � HE-01a34-Ot