HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELL RECORD 2 217 6
l '
Minnesota Statutes Chapter 1031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) 7i7ompleted
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Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Dug
❑ Auger ZRotary I I Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
N fgaclF sand buildings. DRILLING FLUID
I I I �� t.-__,•- � r
,
i ,USE I-.1 Heating/Cooling
-❑ Domestic ❑ Monitoring
-+- --- �- �- - ❑ Industry/Commercial
W , i EElIrrigation ElPublic
El Test Well El Dewatering O Remedial
CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
Cl-Steel ❑ Threaded ❑ Welded
, 1
❑ Plastic ❑
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME ! in.to / ft. / lbs./ft. in.to - ft.
j in.to ft. lbs./ft. in.to" ft.
Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft.
SCREEN OPEN HOLE
Make from - ft.to
Type Diam.
Slot/Gauze Length
Set between ft.and ft. FITTINGS:
STATIC WATER LEVEL
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO ft. K below ❑ above land surface Date measured
MATERIAL
PUMPING LEVEL(below land surface)
-j....">..I �>:-....�.t - - :'.1(• --- ft. after._ ..hrs.pumping g.p.m.
�- WELL HEAD COMPLETION
/ �rz�. p Pitless adapter manufacturer�! "� -F' __ Model
`, ❑ Casing Protection L 1 12 in.above grade
1<. •/ G'!•'%a� �. .!�`} GROUTING INFORMATION
Well grouted? ❑ Yes k No
Grout Material ❑ Neat cement ❑ Bentonite
( from to ft. ❑ yds. ❑ bags
._{ / �• , from to ft. ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
r
NEAREST KNOWN SOURCE OF CONTAMINATION
feet 1 r 'a., direction . ..,.
type
Well disinfected upon completion? �1 Yes ❑ No
PUMP
❑ Not installed Date installed
i
-I• '' � „! /,7 �"'��' Manufacturer's name
Model number HP J Volts
Length of drop pipe ft. Capacity ,g-p-m.
Pressure Tank Capacity
Type: LS Submersible ❑ L.S.Turbine ❑ Reciprocating ❑Jet ❑
ABANDONED WELLS
C f J 419 Does property have any not in use and not sealed well(s)? ,(I Yes ❑ No
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,if needed ;`�j •r �l•;r/�,;>�
REMARKS,ELEVATION,SOURCE OF DATA,etc. _ Licensee Business Name Lic.or Reg.No.
Authorized Representative Signature Date
•Name of Driller Date
MAR 1953
LOCAL COPY 522176 HE-01205-04(Rev.5/92)