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Home My WebLink Aboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELLRECORD 5 6 3 2 (l Minnesota Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fractio�.n{� � WELL DEPTH(completed) Date Work Completed (\v , � �� 1'W 1 Evl�•1v./tiv. 1dt n. '7 Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD 1 L ? 7 711 Cable Tool ElDriven ❑ Dug N . .u! v ✓ r >^r..i ❑ Auger W Rotary ❑ Jetted Show exact location of well in section grid with'X.. Sketch map of well location. ❑ j Showing property lines, N roads and buildings. DRILLING FLUID 14 ,USE Domestic ❑ Monitorin ❑ Heating/Cooling -�- -=- �- �- •, g IN i ; t E� N� ❑ Irrigation ❑ Public ❑ Industry/Commercial -1- -�- -,- _- ❑ Test Well ❑ Dewatering O Remedial f-mi. '�}`'-��, � '(` CASING Drive Shoe? ❑ Yes 97 No HOLE DIAM. -'- - -r- I `-.--r-' ❑ Steel ❑ Threaded ❑ Welded .' i , 1 fi7 Plastic ❑ �—l milr r q Oil r 1 CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME ff I,,.to 9 ft. lbs./ft. -it-in.to ft. in.to ft. lbs./ft. "r in.toJtlk. ft. Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft. SCREEN OPEN HOLE I} Make �f L..., Q A from ft.to ft. Type G. Diam. n Slot/Gauze 11 Length J Set between I ? k ft.andft. FITTINGS: X it i7 N< F HARDNESS OF STATIC WATER LEVEL GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO 911 ft. below ❑ above land surface Date measured �� PUMPING LEVEL(below land surface) If kI1 ft. after L hrs.pumping a J g.p.m. l •1 WELL HEAD COMPLETION r CK Pitless adapter manufacturer i..-F_ '" C� Model LI Y V 1 pf C� ❑ Casing Protection ? 12 in.above grade _�� (. a d GROUTING INFORMATION Well grouted? kW Yes ❑ No ��•y J \ C , S ` ,G_'a. Grout Material �a Neat cement AD Bentonite J t from to1.4 N ft. _ �W yds. ❑ bags from to ft. ❑ yds. ❑ bags from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION C.J feet direction L,,O# type Well disinfected upon completion? (K1 Yes ❑ No ,-,Q PUMP r ❑ Not installed Date installed Manufacturer's name f P W5: Model number HP„ Volts �k Length of drop pipe /_� ' ft. Capacity 1 g.p.m. 1 Pressure Tank Capacity Type:p7 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)?,A Yes ❑ No WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in thffis report is true to the best of my knowledge. Use a second sheet,if needed tl _ I f r(- "� -7 \ ,:(_J REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. � j AtSthoBzed Pirpresentative Signature Date Name of DrAgr Date LOCAL COPY � 535632 HE-01205-04(Rev.5/92) Minnesota Well and Boring H 58024 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. County Name WELL AND BORING SEALING RECORD Minnesota Unique No. HMinnesota Statutes.Chapter 103/ or W-series No. `- ir'N h (Leave blank if not known) Township Name ITownshipNo. Range No. Section No.IFraction(sm. .1g.) Date Sealed Approximate Date Well .\ or Boring Constructed I/4 t/4 I14 } Numerical Street Address or Fire Number and City of Well or Boring Location - j - Ll j �, i Depth Before Sealing ft. Original Depth ft. yam' _.. ��,,,✓ t � Show exact location of well or boring Sketch map of well or boring Static Water Level 9,Accurate In section grid with"X location.showing property lines. N ( roads.and buildings. ❑Approximate I I / r 1 LASingle Aquifer ❑Multiaquifer ftbelow above land surface � i ! _I_ _ _ _>__ _I_ y CASING TYPE W E I I I I T I I iM ( ,Steel ElPlastic ❑Tile ElOther h m I I I I S `–y -fScreen from to ft. Open Hole from to ft. I mk — ' �I ! � OBSTRUCTION/DEBRIS/FILL PROPERTY OWNER'S NAME Obstruction ❑Debris ❑Fill Type of debris/obstruction Mailing Address If different than property address indicated above. Obstruction/Debris/Fill removed? a.Yes ❑No PUMP 1 r Removed ❑Not Present ❑ Other CASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversize hole? Annular space initially grouted? If not known,indicate estimated formation log from nearby well or boring. \ in.from to ft. ❑Yes LINo ❑Yes ❑No 3,Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: 9 No Annular Space Exists ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to K. ❑Perforated ❑Removed Type of perforator ❑Other GROUTING MATERIAL • Grouting material from to ft. yards bags from to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to ft. yards bags V 1 from to h. yards bags UNSEALED WELLS AND BORINGS t Other unsealed well or boring on property? {..Yes No I - LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. I Contractor Business Name License or Registration No. Authorized Representative Signature Date LOCAL COPY H 58024 Name of Person Sealing Well or Boring HE-01434-01