HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CounlyName WELL��RECORD � -� � ��
` Minnesota Statutes Chapter 1031 `^' -y- � � ' �
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 DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Dug
❑ Auger � Rotary ❑ Jetted
Show exact location of well in section grid with"X". �c�c, Sketch map of well location. ❑
J oY Showing property lines,
N roads and buildings. DRILLING FLUID
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� � � � ,USE ❑ Heating/Cooling
__+_ _�_ _ �_ �Domestic ❑ Monitoring ❑ Industry/Commercial
yy � � I E ❑ Irrigation O Public ❑ Remedial
' , T ❑ Test Well ❑ Dewatering
_1_ _1� __ S_ I ❑
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f-mc CASING Drive Shoe? ❑ Yes � No HOLE DIAM.
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—�— �— — r- ❑ Steel � Threaded ❑ Welded
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� Plastic JQ (31�
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CASING DIAMETEA WEIGHT
PROPERTY OWNER'S NAME 4 in.to �3 ft. Ibs./ft. � in.to+�8 R.
J. p� in.to fl. Ibs./ft. in.to ft.
Mailing address if different than property address indicated above. in.to ft. Ibs.ttt. in.to ft.
SCREEN OPEN HOLE
Make J(� from ft.to ft.
Type �^ Diam.
SbUGauze v1.g Lengt
� Set belween �3 ft.and�tt. FITTINGS:
STATIC WATER LEVEL
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO �e 1n
MATERIAL '�e.l h� �below ❑ above land surface� Date measured 08/1L/92
_ _ PUMPING LEVEL(below land surface)
�y Q � ft. after_ hrs.pumping 1� g.p.m.
WELL HEAD COMPLETION
�� � t�n^aZ�Dl � �Q �Pitless adapter manufacturer ��.�ca Model �
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❑ Casing Protection ❑ 12 in.above grade
S[ � � 3O 55 GROUTING INFORMATION
Well grouted? �Yes ❑ No
Cl.c1y gray 55 �,� Grout Material II Neat cement ❑ Bentonite
X
�� from �to_�_ft. ❑ yds. ❑ bags
_�,�'w /�,, 1Gn from to ft. ❑ yds. ❑ bags
►��� �t S�Y��.c �/a�l 1�0 1�7V from to ft. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
Z('Y'a�l & $a� r� y� 178 feet _ direction rype
Well disinfected upon completion9 ❑ Yes ❑ No
PUMP
❑ Not installed Date installed�ABT�QT/O'Z'
Manufacturer's name 1+�..,7.i..
Model number HP�_ Volts��.__
Length of drop pipe �_tt. Capacity � g.p.m.
Pressure Tank Capacity
Type: {�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
C Does property have any not in use and not sealed well(s)? ❑ Yes No
CITY 0 �
WELL CONTRACTOR CERTIFICATION
, �� � This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Use a second sheet,il needed S'�{�$ �,]► , �t��7�7 (;Q.� Ij�`� 86659
REMARKS,ELEVATION,SOURCE OF DATA,eta Licensee eusiness Name Lic.or Reg.No.
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�E F� 1 1 'i�9� � ...«. � _ _--�_.
Authorized Rept sentative Signature
Rax�dv Jd�nsan 08/12/92
�" ame oi Driller Date
LOCAL COPY 514 2 7 5 HE-01205-04(Rev.5/92)