well info - Laserfiche WebLink

Home Browse Search

� s a WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. • County Name WELL AND BORING RECORD 6 4 9 2 4 3 Aenn�pin Minnesota Statutes Chapter 103/ � Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. �a v. v. � House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD Cl Cable Tool ❑ Driven ❑ Dug � [] Auger f�Rotary ❑ Je[ted '�� Show exact location of well in section grid with"X". Sketch map of well iocation. ❑ _____._ ..__ . `. Showing property lines, - � �� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �NO N i i i i � FROM_ ft.to_ _fl. _i_ ___ ___ _i_ r` USE ❑ Monitoring ❑ Heating/Cooling i i i i C Domeslic � ❑ Communiry PWS ❑ Industry/Commercial i i i i �� ❑ Irrigation ❑ Noncommunit PWS �� yy E T � ❑ Environ.Bore Hole Y ❑ Remedial � i � i i ❑ Dewatering ❑ _ i -, i i +ZIM1e CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. - _i i i _�_ ❑ S�eel �.".i Threaded ❑ Welded - i - i- -i - i 1 x[7 Plastic �F� ��.sA _ S �—,M,�e_� �/ �``� ��"��`�--'�""� � --f^� CASING DIAMETER WEIGHT � PROPERTYOWNER'SNAME �_in.to..�.��__ft. SI�g��. Ibs./R �J ��t� 3� �lC�iar� Ot Dariene Yiarki� in.to tt. Ibs./ft. �y� in.t�1��ft. F�r - Property owner's mailing address it different than well location address indicated above. in.to____ ft. ____ Ibs./ft. in.to ft. _ SCREEN OPEN HOLE Make_��]� from ft.to ft. Type��a�-a-i$��__��r�� Diam. „ � SIOVGauze Length ��_ ______.___. ._.. • � Set between __.. __ft.and_'�'_¢'�___ft. FITTINGS:'�_g_� � STATIC WATER LEVEL ' WELL OWNER'S NAME a� _____ .__ n.� below ❑ above land surface Date measured 8�_�_�� PUMPING LEVEL(below land suAace) ", Well owner's mailing address if differeM than property owner's addiess indicated above. �___________ft. aRer__�� hrs.pumping____�. __ g.p.m. : Y; WELL HEAD COMPLETION t ' �Pitless adapter manufacturer�,,,a,JY\,��u�[��fi r Model ._....______._ ❑ Casing Protection______ _ T�12 in.above grade - ❑ At-grade(Environmental Wells and Borings ONLY) 6 GROUTING INFORMATION Well grouted? f�i Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� wNeat cement ❑ Bentonite ❑ Concrete ]Q High Solids Bentonite MATERIAL from__�_ to�Q___ft. _"�_� ❑ yds. C�bags from��__td�4.�..__tt. �$�.�}.�llyds. [.1 bags Cla ys,ll Y 3 0! $81 from [o ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION ,-,� Ci� Qr$ S Zii� 7V� ,r,:a feet s� ___direction _ ,�.-�_3 .Iutle�,.. Well disinfected upon completion? �� Yes ❑ No �... � Gravei& Cla Gra S 'Q� g � PUMP .^, Notinstalled Dateinstalled R��7�nn l Sand S� CLa B Qm at � �Manufacturer's name ______ _ Modelnumber HP_��.__ Volts L�� �� F��e Saad b S 1 � �Length of drop pipe_ ZOS� ft. Capacity _____. .,._... _.__g�p.m. �� Type:�I Submersible .�.� LS.Turbine ❑ Reciprocating CI Jet ❑ aIId � ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes 'F�'No VARIANCE Was a variance gran[ed from the MDH tor ihis well? ❑ Yes '�1'No TN# _ f` WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in ihis report is true to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA,etc. DOI�L_�T�DAL� iTSLL DRt?.T.TItG �/,�./v��-� jj�jC.___ � t Licensee Busines ame Lic.or Reg.No. , 87172 — ___ - uthorized Repres ative Signature Date 6 4 9 2 4 3 Name o ri er ate LOCAL COPY HE-01205-07(Rev.2/99) �