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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
WELL RECORD .- �� �
County Name � ("� � �
t , ,� : <<, �. �� Minnesota Statutes Chapter f031
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Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion
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Numerical Street Address or Fire Number and City of Well Location DRILLING METHOD
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� CableTool I I Driven L] Dug
,i `j-,i ;!, ,j<'1 i i;' l ❑ Auger �.Rotary C Jetted
Show exact location of well in section grid with"X". Ske'tch map of well location. C]
Showing propertylines,
N �,� roads and buildings �� DRILLING FLUID
I i y _1_ /� j 1 i 7 �._ `;:
--r- 7- - i � � ± 1 .� 'vJ"'
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i � � � .--._, � j USE
�-�- -;- �- �' � �; �t �Domestic ❑ Monitoring ..J Heating/Cooling
W � E , j � �Irrigation L I Public Industry/Commercial
_1_ _i_ _'_ __ T � J} � � C Test Well ❑ Dewatering
� � i I �C 5 �,. � `` ^'�
' f-mc � ��,,; i CASING Drive Shoe? � : Yes .: No HOLE DIAM.
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--i- �- - —�" 1 ! ❑ Steel Threaded :] Welded
�_�m,le� t ,`?.i � Plastic i..l
' CASING DIAMETER WEIGHT
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PROPERTY OWNER'S NAME ��in.to ) i'= tt. ,� ..�2. Ibs./ft. �in.to�ft.
- _ � in.to ft. Ibs./ft. ��in.to�+ :Wt.
Maili'ng address if itterent than property address indicated above. in.to tt. Ibs./ft. __in.to_ft.
/ r, G, r �. ;'i'. , " s j fl� G+' SCREEN ` OPENHOLE
� �_� J � /y ` - Make�', .��!� � from ft.to ft.
��J r .„ / �F�r,'-'r� �.�1 � 1 ,t�/J� , �..J r ? !J � TYPe t'�`,. L_... Diam. [/�% _ .
;� � ' SIoVGauze �7 r� Length �(
Set belween�_) !_ ft.and ,Z,�D ft. FITTINGS: � �
STATIC WATER LEVEL
FORMATION LOG COLOR HARDNESS OF FROM TO ` J"� ft. below � above land surtace Date measured r '"i
FORMATION � �C. r P�
PUMPING LEVEL(below land surface)
� ,, :" � � 1 f` ft. after � hrs.pumping Zf` fl.p.m.
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` WELL HEAD COMPLETION
� t ;�_�e" r � � r ` / �.�Pitless adapter manufacturer L,.,1� � 3.`� Model �" 7 f .. �"'"
�� ! I 7 Casing Protection
' ' GROUTING INFORMATION
�,.. � �`'-«,.... �i �. ,{'
Well grouted? �Yes C No
{ „ J �;'� � } � Grout Material L,�[Neat cement ❑ Bentonite
�f from v„ro Tr ri. L I yds. ❑ bags
! from to ft. ❑ yds. ❑ bags
r ��{�, y( ,�j;., r � . / f} �d a from to ft. ❑ yds. ❑ bags
NEAREST SOURCE OF POSSIBLE CONTAMINATION
,r�! �' r. � ry.-- / ,� ✓ � � .)� � S feet E direction _,���.._..,��J tyPe
♦,'� � Well disinfec[ed upon completion? �Yes ❑ No ;� - ��
PUMP
C; Not installed Date installed '�� �` � �'t
' Manufacturer's name -i�T,... i`_..aG..
Model number� �& �._ HP '/� Volts � � J
� Length of drop pipe� n tt. Capacity 1 � fl.p.m.
f� Pressure Tank Capaciry ) a > �r T�, �
Type: C�6ubmersible ❑ L.S.Turbine ❑ Reciprocating _ Jet ❑
ABANDONED WELLS
Not in use and not sealed well on property? ❑ Yes C3xVo
WELL CONTRACTOR CERTIFICATION
This well was drilled under my jurisdication and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
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Useasecondsheet,ilneeded % L' !:�.;,�''`f c:i l v" / fc
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REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee usiness Name ` Lic.or Reg.No.
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�, <� � r �: ,� r� �- �r .�
'Autfiorized Representative Siganture Date
�'d /,;;�: ,,�. t! �: i .�
Name of Oriller Date
LOCAL COPY � � � d� � HE-01205-03(Rev.9191)
STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABA(VDONED WELL RECORD
i. �oc�TroM ov uEu , _' "I�INNESOTA UNIQUE WELL N0.
( (leave blank if not known)
County Name ��,� �� �' � i I .
Tovnsnip Name Tovnshi Number Range Number Section N� Fractian 4, d6L UEPTH (completed) Date sealed,
' � E k 4 of k
� � I J l � .:� j or . �� ft. � _� j.
' %��; „-._;, _ ' a� �
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iNumerical Street Address and City of '�ell Location or Distance from Road �S. GRIILING METHOD (if knoxn)
Intersection ,C�able tool 4[]Reverse 7(��riven 10�Dug
� { �/� / �'2�,���� //� , J� � �`L+ � � "FToliow Rod 5[�Air 8[]Bored 11[]
/ l <�
Show exact location of well 30 Ratary 60 Jetted 9�Power Auger
(fn section grid �ith "X") / Sketch map of well location 6. OBSTRUCTIONS
N �N ' Nell obstructed�Yes � No
_ � _ : _ ,_ _� � Obstructions removed�Yes [J No If obstructions cannot De
� • i � �� � removed, contact NOH
� � ' ' before sealing.
►+ - - - - • - - - -I- - E
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_ : : , ; T v�y � �. �sE
•- • • - -- y� � l�f Domestic 40 Monitoring 8[]Heat Loop
• . y� 4 2C1 Irrigat1on 5�Public 9� lndustry
' � � � i -�—�- S iC � ,iLJ iest Mel7 oU Nunicipai lC[�J Comrkrctal
�1 S�_ I � 70 Air Conditioning 11�]
2. PROPERT�Y ONNER'S NAME Maiting Address 1f different than 8. CASING(S)
(;w_��� property address indtcated above 1[]dlatk 4[�r]Threaded 7[]
/' p/ / 2�Ga 1 v. 5Q We 1 ded
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V ��� ��'�^'✓" w 3L]Plastic 6(]Stainless Steel
HARDNESS OF /��f"-- {t•
3. FORlfATION LOG COLOR FOKMATION FROM TO '1- �n. to_j2=
If not known, indicate formation log from new well or nearby well. 1n. ta ft.
I 9. SLREEN —
� .�Screened wel l from��t, to ?V ft.
r-- (If known)
_ 7--- � � �-' ❑Open Hole from_ft. to_ ft.
10. STATIC WATER LEVEL
�-� ft. �below []above I
land surface Date Measured � -�� ?
11. 41ELLNEAD COMPLETION
1(]Vltless Adapter 40 Found Buried
2f�Basement offset �
3(]uell Pit
I16. REMARKS. E�EVATION, SOURCE OF DATA - CASINGS REHOVED, CASINGS PERFORATED, ETC.
I 12. GROUTING INFORMATION
� l�v-Neat Lement 2�Bentonite �
iGrout material � �zfrom�':to Qft. cu. yds
I — — --�
13. HEARE57 SOURCES OF LONTANINATION ��/
' 1�feet (.�✓ dlrectlon C�'Z.y�-�-� type
'�elt disirtfected before sealingt (�Yes
I
14. PUMP �Removed � Not Present
Type: 1[�Submersible 30 L.S. Turbine � Reciprocating
� �Jet 40 Centrifugal 60
15. EX(STING WELlS (Please sketch locationz of abandoned and
active wells in remarks section or on back.)
Other unused well(s) on property7 �Yes � No
Abandoned: [] Permanent �Temporary �Not sealed
17. NATER NELL CONTRACTORS !:ER7IFICATIOM
TM s well was sealed ,:nder my jurisdiction and this report
is true to the best of my knowledge and belief.
- - ��� � 1� � �d� L
ltcensee Busin�s Name �Y,License No. _
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Addre55 '�'L ^ '�-�
Signed i � _� Date C ' / `'9 �
�----�--�- G't-- Date �� �� �-
iFTCIAL ABANpOHED MELL RECORD (May be used for ProDerty Transfer) � e of �riller . �
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