HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELL AND BORING RECORDamnevin a
Minnesota Statutes,Chapter 1031 F 7
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
H.
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GPS DRILLING METHOD
LOCATION: Latitude degrees minutes seconds
Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug
❑Auger Rotary ❑Jetted
House Numb Street Name,City,and Zip Code of Well Location jor Fire Number ❑ '
N=h ShOM Dr W. Orono DRILLING FLUID WELL HYDROFRACTURED? ❑Yes X10
ow exact location of well in section grid with"- ". Sketch map of well location. wat c FROM ft.TO ,/` ft.
Showipg property lines,
N (� lu6ds and buildings USE El
�1 Monitoring ❑Heating/Cooling
__;_____;_____;__ ;__ '-} Domestic E]Environ.Bore Hole ❑Industry/Commercial
Noncommunity PWS ❑Irrigation ❑Remedial
Community PWS ❑Dewatering
❑
- t ^Comm
CASING HOLE DIAM.
W E Drive Shoe? [I Yes 4,,1#N0✓
❑Steel El Threaded 11 Welded
Mile Plastic
❑
r --------- 1
\ ---""'J��• CASING DIAMETER WEIGHT
1 s 1 \l
��- i in.to M ft. 2.41 lbs./ft. in.to 30 ft
—1 Mlle { .
in.to ft. lbs./ft. in.toi
PROPERTY OWNER'S NAME/COMPANY NAirE in.to ft. lbs./ft. in.to ft.
Un-Agrp-nSCREEN OPEN HOLE
Property owner's mailing address if different than well location address indicated above. Make%
TFROM
. TO
ft.
545 Indian Mound E Type stl Dia
SIoUGauze Length 41 44,Layz55391
Set between ft.and ft. FITTINGS
STATIC WATER LEVEL
10 -ft. elow ❑above land surface Date measured 4—
WELL OWNER'S NAME/COMPANY NAME
PUMPING LEVEL(belAt land surface)
19�y0
ft.after 2 hrs.pumping 95 g.p.m.
WELL HEAD COMPLETION
Well owner's mailing address if different than property owners address indicated above. y�—�y�'/p'ltless adapter manufacturer �.temitet Model
{�Casing Protection in.above grade
❑At-grade(Environmental Wells and Boring ONLY) T
GROUTING INFORMATION
Well grouted es E]No
Grout material Neat cement
L]Bentonite ❑Concrete�igh Solids Bentonite
from to 30 ft. ❑yds. 1Aags
from to ft.�ilii C bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. _
MATERIAL ❑yds L-bags
NEARESTKNOWNSOURCE OF CONTAMINATION
feet 1V Ziirdirection type
Well disinfected upon completion es ❑No
PUMPclay soft 2n -80-
y��tt
❑Not installed Date installed
4-4
Msand - gray sof r An 17nanufacturer's name
Model number HP I j Volts
clay r. Length of drop pipe 1,471 ft. Capacity 9—
p.m-Type:56ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑
sandigravel -Rnfr155 2MABAINPONED WELLS
Does property have any not in use and not sealed well(s) ❑Yes 0
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes o TNk
WELL CONTRACTOR CERTIFICATION If
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
REMARKS,ELEVATION,SOURCE OF DATA,etc.
We!- 27172
Licensee Business Name o.
5-4-04
o epr en at/ve Signat/+�,,,��k y�,� 4-2&-04Dattee
LOCAL COPY_ 705941
059 1 Name of Driller
.,
HE-01205-08(Rev.5/02)
IC 140-0020