HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUE WELL NO.
County Name WELL AND BORING RECORD 6 g� 5 3 9
Hennepi n Minnesota Statutes Chapter f031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Com eted
Orono 118 23 31 NW SE SE "
,,, ,, , 15Q 3/4/04
GPS DRILLING METHOD
Latitude degrees minutes seconds
LOCATION: ,�Cable Tool ��Driven � ]Dug
Longitude degrees minutes seconds �.-- —�
_i Auger �Rotery �Jetted
House Number,Street Name,City,and Zip Code of Well�ocation or Fire Number i`
525 �CC111�.� Rd• w2l zata, �n 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �No
Shop exact location of well in section grid with"X". Sketch map of well bcation. Baro i d qu i k gel FROM ft.TO ft.
Showing property lines,
N roads and buildings USE , I��Monitoring [�Heating/Cooling
-� ; � ; .--� L i Domestic ❑Environ.Bore Hole �Industry/Commercial .
--'--- '-----� _ 1 _. .
" �i Noncommunity PWS ��Irrigation J�Remedial
�J Community PWS i_]Dewatering �
: 1 � ,,��....._, —
'--" ""' - ---� ` �' CASWG� Drve Shoe? ❑Ye f'�� HOLE DIAM.
w E 1.� . .. -, ..i s No :
' ' T . � .. Id d
� --> Steel hreaded e e
-- -- — -- - - �J �J T ❑W
- � - - - � � � .. . � Plastic —,
. 'hI Mile .... .. � fr. .,.� � L' ':
�. '--' """ ' f- 1 . --�� �^""' CASING DIAMETER WEIGHT �
� S 4 �,,.to 14 0 n 1.9ibsJft. �� m.to 3� rc. '
�-1 Mile� /
f, . .t� /}�,'(� - ..__.._. in.to tt. IbsJft. 6� in.t��Q ft.
..t f
� PROPERTY OWNER'S NAME/COMPANY NAME .. in.to fl. Ibs./ft. in.to_ ft.
Chris Stie hens Cdnst.• SCREEN OPEN HOLE
Property owner's mailing address if different than well location address indicated above. Make___Cres1 ne FROM tt. TO ft.
Type�la$�iC rN
37?5 CO. Rd. 92 SIoUGauze �� Length ��_ea �
Mez le Plafn, Mn 55359 Setbetween 14f1 ft.and ��}A ft. FITTINGS
P STATIC WATER LEVEL
__v�_ft.i�below � ,I above land surtace Date measured___�.��_
PUMPING LEVEL(below land surface)
WELL OWNER'S NAME/COMPANY NAME
5 ft.after__ �__hrs.pumping � g p m.
WELL HEAD COMPLETION
Well owner's maiting address if different than property owners address indicated above. ��pitless adapter manufacturer��'1��e'� -Pt' _ Model�.u__l�___
Casing Protection [�12 in.above grade
[i Ahgrade(Environmental Wells and Boring ONLY)
GROUTING INFORMATION
Well grouted ��Yes [j No
Grout material i�;Neat cement ❑Bentonite ❑Concrete�High Solids Ben[onite .
from 30 to � tt. � ❑yds. QQ bags,
" from__to tt. �j Yds ,_�bags I
GEOLOGICAL MATERIALS COLOA HARDNESS OF FROM TO from_, to ft ��,Yda �_,oags� ,
MATERIAL
NEAREST KNOWN SOURCE OF CONTAMINATION �I
yelTar� elay br�wn soft 0 35 ��_ ree� _north direction _$ePt�C tyPe
Well disinfected upon completion �',Yes �,No tank
blU$ C.l.a� C�Xa� LROfL 3S $� PUMP
I Not installed Date installed
Cl�Y � eand gray 80g1'i 85 13 'rJ IManufacturer'sname Aarmotor
.a e Modelnumber HP 1 _1/�o�lfts "O
� garlu gray $�f t'i i 3.l 150 Length of drop pipe 1 ft Capacity `O g.p.m.
i —
. Type�Submersible [I LS.Turbine 1-I Reciprocating '�Jet [;
�� ABANDONED WELLS
Does property have any not in use and not sealed well(s) ��Yes I No
VARIANCE
Was a variance granted from the MDH for this wel�? ,___�Yes I No TN# -
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The intormation contained in this report is true to the best of my knowledge.
Use a second sheet,if needad A
REMARKS,ELEVATION,SOURCE OF DATA,etc. Le11t.YLII@r we�.l Inc. 1 V 1 ZS
Licensee Business Name _ /'`� Lic.or Reg.No.
,'� � �
�, -� ' � ti/�y
J
AJthoriied Representative Signature � Date �
Maurice L. Leuthner 5/21/04
�9 2 5 3 9 Name ol Driller Date _ .
LOCALCOPY Ne-o�zos-oeiae�.sioz� ,