Well info - Laserfiche WebLink

Home Browse Search

t:. ..,�_... .. � r�. ,�.-�,.. ._ ,F�.I ..r.. � . . i'� ri t"f;�"fa� !R'9ET' �dv 6..J��9�' _ . ' .. _.. �. :.�. �t-F:.. , , . ,� . .�._ �. � ,. . . .._. _,... . .� . .�J. �v'+$�'":.k':..iw � . . ... . .r. . �'".�r �,.� . . . .... .-... ., .,,.. .' WEL�OCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. � Counry Name WELL AND BORING RECORD 7 � � �� Minnesota Statutes, Chapter f037 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. v, y �i GPS DRILLING METHOD LOCATION: Latitude ___ degrees minutes seconds _ Longitude degrees minutes seconds i J Cable Tool I�'Driven � ��.Dug � — �Auger �Rotary ��Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �� � DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No ; - - Show ezact location of well in section grid with"X". Sketch map of well location. �t��e FROM ft.TO R. Showing property lines, ' N roads and buildings USE . Noncommurnt PWg I`�I Mo ation 9 ��Heating/Cooling J `� � � �Domestic Y � � 9' L J Industry/Commercial �� . .___ , ___�__ _._ _ . I Environ.Bore Hole � -� � Remedial ' ' ' ' ❑Community PWS L_�Dewatering r�� � , � _ �r ' � � 1� CASING HOLE DIAM. - w eT � .G,� Drive Shoe? �Yes �No � : --;--- --;-_ __�_____�,_ I � . [,Steel ❑Threaded ❑Welded '� 'h Miie � Plastic � P� ; ; ; ; � -� - � � � � CASING DIAMETER WEIGHT . � � S � � F---iMile—� /, ,�� '-`_�,.�x„ :j� � , —� in.to �"!� _ft. ��0� Ibs./ft � in.to �Q��. I "-'�"�`�J in.to__ ft. IbsJfL �in.to �"��ft. �� PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./tt. in.to ft. SCREEN 2nJ...�w... OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make _ FROM ft. TO ft. � � a1..,�.� Type Diam__�_ _ [7V�C �� SIoVGauze "'-" ��Length�� }�f �.�� Set between � ft.and �l ft. FITTINGS R N � ' STATIC WATER LEVEL � - , ... _ �+ ft� .below ❑above land surtace Date measured V J v5 PUMPING LEVEL(below land surface) � WELL OWNER'S NAME/COMPANY NAME �� q /� � ft.after_ �+ hrs.pumping �v � g.p.m. WELL HEAD COMPLETION Well owner's mailing address if different than property owners address indicated above. �,pitless adapter manufacturer u�.�u�+��'h�Mo el [,Casing Protection �2 in.above grade �'�.Abgrade(Environmental Wells and Boring ONLY) � GROUTING INFORMATION Well grouted �Yes ';J No �^ Grout material �,�Neat cement ❑Bentonite�[�ConcretQe,rc�High Solids Bentonite from O to �"'_ft. ^✓ ]yds �Fiags from -^✓ to `�7 ft. �� Z ❑bags GEOLOGICAL MATERIALS COLOR H MATERIALOF FROM � TO from to ft � g ❑yds. �ba s NEAREST KNOWN SOURCE OF CONTAMINATION ��" �+. ��..a feet y,,,}.� direction Well disinfected upon completion ''Yes �J No �.;,1 � PUMP !Not installed Date installed "3� ' f Y/ � rJ'`J Manufacturer's name ..,��r.�� <��-- Model number HP '"��'�J Volts i.J�-'� / .� Lenyth of drop pipe /� .�v` ft Capacity g.p.m. Typ Submersible �.j L.S.Turbine r1 Reciprocating jJ Jet [j ABA DONED WELLS Does property have any not in use and not sealed well(s) ;]Yes - o VARIANCE Was a variance granted from the MDH for this well? Lj Yes No TN# 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,il needed }�,�� ��-�� REMARKS,ELEVATION,SOURCE OF DATA,etc. LVi! SL�OI� ��I��1� W�• iT�C• G�7Z 1`� �r�� n�.+��1 � �t t� 20�� Licensee Business Name Lic or Reg.No. 1 ....-""" .r /�_ .� c:,�� h ze epresentative Si Date t Chvck �crre - < �OCAL COPY �� +} � Name of Driller L HE-01205-08(Rev.5/02) ` IC 140-0020