HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL RECORD � 5 3 5 6�, 8
�� Minnesota Statutes Chapter 1031
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Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
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Numerical Street Address and City of Well Location or Fire Number DfEILLI G METHOD
.- t�`, ,� ; ❑ Cable Tool ❑ Driven ❑ Dug
1��,.(��; f �v"��i... �.✓ ✓h � �/ . ❑ Auger � Rotary Ll Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
N roads and buildings. DRILLING FLUID
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i � i i � � X ,USE �Domestic ❑ Monitoring � Heating/Cooling
yy i � i � E ""`"'� ❑ Irrigation ❑ Public ❑ Industry/Commercial
_1_ _s_ __ __ T ❑ Test Well ❑ Dewatering O Remedial
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� f-mi. CASING Drive Shoe? ❑ Yes .Dl No HOLE DIAM.
--�- �- � -�' I ❑ Steel ❑ Threaded p, ❑ Welded
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�l Plastic ❑
�1 mile-� (�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME �_ J�(, ? '
in.to ft. Ibs./R �in.to,}�l ft.
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Mailing address if different tha property address indicated above. in.to ft; Ibs./ft. in.to ft.
. � SCREEN OPEN HOLE
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t �'. � -. ��`�'=+ C: v csi �„ �� L^.�.Y'�(''`� �f S ''- Make •.�r L..n ja v�. from ft.to tt.
� " Type _" '� Diam.
� p,, SIoUGauze I ,� Length_; �
� � �' V T��= `'�'` 1'1"` � � �j i � Set between � 3� ft.and�_��:;_ft. FITTINGS: a X <� !' ';"t�=''t1'
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HARDNESS OF STATIC WATER LEVEL .
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO "�' � �
�� ft.�below ❑ above land surface Date measured 1� ` �.,.3'
PUMPING LEVEL(below land surface) �:
� �,, ��3 �,��j�, /� � � ) ���d,,� ft. after �. hrs.pumping ��� g.p.m.
WELL HEAD COMPLETION .( ` , � +
� �r � � � �l Pitless adapter manufacturer Lr.f`". '�° �/ 4 i eModel ��/Z X ��,�
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❑ Casing Protection �l 12 in.above grade
�} � �� r� t p,1 ���,} GAOUTING INFORMATION
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Well grouted? �.Yes ❑ No
�� d Grout Material �J Neat cement � Bentonite �
from�__to�_ft. � �7 yds. ❑ baqs
from to ft. ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
���feet �j��---� direction ���-s�'�'1 � type
Well disinfected upon completion? �l Yes ❑ No
PUMP +�
R ❑ Not installed Date installed � � " j
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Manufacturer's name 1�1 F ��J".
Model number HP.� � Vo1lts �.T�-�`
APR Length of drop pipe '�.,;� ft. Capacity � d, g p m.
Pressure Tank Capacity ���i X� i��o i
C Type:.�l Submersible ❑ LS Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes � 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,if needed �+�� �; '3 `,� �"
_ �,.= 1 .c.. `�� �.
REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name Lic.or Reg.No.
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uthorized Representative Signature Date
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Name ol Driller Date
LOCAL COPY � �� � � � HE-01205-04(Rev.5/92) �