HomeMy WebLinkAboutwell info 4���� .. .. . _.. .�.....
STATE OF MINNESOTA DEPARTMENT OF HEALTH
ABANDONED NELL RECORD
i. �oCArIOH oF uE�� MINNESOTA UNIQUE WELL N0. �-
_ (leave blank 1f not known) � �
Coun,y .4am!
,p��- .�{�
Townsnip Name Township N mcer Range Number Section No. Fraction 4. WELL OEPTH (completed) Date seAled
N E h h of y
I �"1��.�`'— l l 7 Sr � .� yr � /CI ` ft. /l } L� 7s7
i .Yumer�cal S[reet Addresz and City of ','ell Location or �istance from Road 5. ORILLINf, METH00 (if known) �
� :ntersection .
I 1�]Cable tool a�Reverse 70�riven lOQ Dug
' / (, ) � /� , � 2[] Hollow Rad 5[�A1r 8�Bored 11 I
'� �J 7 �T L / !/L '1.��� ��G•�•L•i.-C �.=i. • ❑
Show exacc locatton of well
30 Rotary 6�Jetted 90 Power Auger
, ;in se;tion qrid with "X"j �� Sketch map of well location
6. OBSTRULTIONS
� Well abstructed�}'Yes � Na
i _ � _ _ . ._ _.. j 1 — Obstructlons removed�Yes �No If obstructions cannot tre
i I .�� removed, contact MOH
y _ _ _�_ , _ � _�_ � _ E ��� � before sealing.
. i i . � . i : i � i 7. USE
j- ' �, ' � -i ' y +i, l�Domesttc CQ Monitoring 8�Heat Loop
� _��7�x� 20 Irrigation 5(]Pub11C 9� Industry
;_ ;_ ., ;_ ., . _... 1 ��
30 Test Well 6�Municipal 1C0 Commercial
$
�--1 riL— 7u Air Gondittoning 11(__j
: 2. ?ROPERTY OWNER'S NAME Mailing Address if dlfferent than 8. CASING(S)
i Droperty address indicated above 1�Black 4�Threaded 7[, I �
�,D�� /{�`V.:�,,,,,,L 2[�Galv. 5Q Welded i
i�`� 6!
3L]Plastic 6�]Stainless Steel
j NARDNESS OF � `
� 3 �ORMATION lOG LOLOR FORMATION FROM TO �n. to /�d J ft.
i I
.f not knovn, indicate formation log from new well or nearby well. 1n. to ft.
I
I I
' , 9. SCREEN
� �]Screened wel l from l v�ft. to��� ft.
(If known)
� �ODen Hole from_ ft. to _ ft. �
` �L= �f I I V 10. STATIL WATER LEYEL
I `�.`'' ft.�below [�above
' Tand surface Oate Measured ��, 3 c��- J�
I
I 11. uELIHEAD LOMPLETIOH
I �'Pitless Adapter 4❑Faund Buried i
� 20 Basement offset `{� �
I 30 Well Pit
16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVE�, CASINGS PERFORATED, ETL.
� 12. GROUTING INFORMATION �
I�Heat Cement 2�BentoMte �
I� Grout material fra��d to� ft. cu. yds
i
� — —�,
I � 13. N�Rq�ST SOURCES OF CONTAMINATIOk ^
J feet ���
i _ � directton Z„�r��c.—,_ type
� Nell dlsinfected before sealingt,0 Ye:
I
l4. PUMP �Removed �Not Present
I
iTyDe: 1[� Submersible 30 L.S. Turbine � Reciprocating I
� --- 2�Jet 4Q Centrifugal 6[�
I �� ��. 15. EXISTING WELLS (Please sketch locatlonx of abandoned and
� � � active wells in ttmarks section or on back.)
. - �-�- Other unused well(5) on property7 �Yes � No
Abandoned: �Permanent �Temporary �Not sealed �
I
i1. 'aATER WEIL CONTRALTORS CERTIFICATION i
_., — This well was sealed under my jurisdiction and this report
is true,7to the best af my knowledge and belief.
DEC � A�.cAa�' � E`� -.0 ��.i� d...�..� � �7
Ltcensee Business Name 'Ltcenye No.
. ` x+-�� '� -
AddreSs � "v ,�1.4
Signed , �-�3'� _ -_/ Date / ��<t v %2
� r
� Date -�J
FFICIAI ABA11ppNE0 YELL RECORD (May be used for Property Transfer) me of Drtller�
ZIlPQtTiIlIT: PILS WZTH OdSD
WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.�
CountyName WELL RECORD � .�������'�....�.
�{r �-�f� � � Minnesota Statutes Chapter 1031
Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed �
tt
' Y�'�r i'7i r� 1 � .? ,3 �� �. '�.,�. / f/ ,�!'�'" j 'L.
Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
-)�, ❑ Cable Tool ❑ Driven ❑ Dug
� ' ❑ Auger �,,Rotary ❑ 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
I � ' '
_'r' y_ _1 —L_ . i� �..
� � �' �� . _ '.r
_a_ ___ i_ �_ J ' ,USE Domestic '� ❑ Monitoring � Heating/Cooling
W � � � E O Irrigation ❑ Public ❑ Industry/Commercial
� T � ❑ Test Well ❑ Dewatering a Remedial ! '
_1_ _1� _'_ 1' I
I n; j �
2-mi. E �'� " r�'�,. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
--�- �- � -r- � ❑ Steel ❑ Threaded ❑ Welded
1 i�+.- �7 -_.. .
Plastic ❑ _
�—I milr'—� :w�.-. r" ~
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME _�__in.to���ft. } �1 Ibs./ft.
e. �in.to.�j�tt.
.".. in.to ft. Ibs./tt. �_�.to�'�ft.
� in.to ft. Ibs./ft.
,� Mailing addres if different than pro erty address indicated above. in.to_ft.
. SCREEN OPEN HOLE
'� Make � �C.�r from ft.to ft.
Type_t,'"� Diam. Y
SbUGauze � �;t'" Length �
Setbelween ! ;�s � ft.and�`�'�_R. FITTINGS: k' �"'�-�_�.. �
HARDNESS OF STATIC WATER LEVEL
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ,7' '� ft.gbelow ❑ above land surface Date measured ��- J✓ f�
�1
�� ,r- PUMPING LEVEL(below land surface) . �:�
f..v,`•2,�,,,� �^,r;E,pQ � � ?�"� ft. after ,g hrs.pumping .f � g.p,rn,
� �
s r � WELL HEAD COMPLETION
t f� ��„�.� � . � (� ['�{ (�Pitless adapter manufacturer tn....�.�..:+!!"L Model � �' _�
,/ �j ❑ Casing Protection ❑ 12 in.above grade
�� /' �� ' S I Q GROUTING INFORMATION
... - - r�++'-eN.
-r-' Well grouted? �7,Yes ❑ No
r...� .,e�
C' f/ � � Grout Material �,Neat cement ❑ Bentonite
������ ¢�`�� � �� from�to��ft. ❑ yds. ❑ bags
�: / f� ��, ar from to ft. ❑ yds. ❑ bags
;' (`. f ,,,,�.s.,�( �Y`'nE.'r�� /� � �� from ro ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION �
� j';jr .,y�, � /ti 2� J ����' �.� feet L✓ direction,�b'�J,.;::,r.. ��d.�'LtyPe
� '�7
. Well disinfected upon completion? ,p Yes ❑ No �
,�� ��.
�
.f �.A� '=7�'.� �t'!'�� ��4/ PUMP , .
❑ Not installed Date installed � f I J � rI t
Manufacturer's name r��..,,.�.,;7�'i•,
� Model number �' S"'�0 i'Y1 HP •�i Volts ���j n
� Length of drop pipe � y ft. Capacity ��„ g.p.m.
Pressure Tank Capaciry �? � Z,
Type: p Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
� r
R
ABANDONED WELLS
s_.� Does property have any not in use and not sealed well(s)? O Yes �O.No
1�
WELL CONTRACTOR CEFiTIFICATION
� 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 � � � ! S � �
� �.r--����J �� ,� :;f- � � .� �
REMARKS,ELEVATION,SOURCE OF DATA,etc. L�censee Busrness Name _ �r' Lic.o�Reg.No.
�Ef y/�—;-'7 �� � � / � `✓I � L
�utho zed Represent� atiJ�2"Signature � � Date
�.,..� "%'/% ..r�!'�.1' �i�..L-v:.c�, // i .'�'-� �--
Name olOrille� Date
D E G 2 �:'��'
LOCAL COPY ��„ 3 8 9 5 He-o,zos-oa�Re�.sisz�