HomeMy WebLinkAboutwell info STATE OF MINNESOTA DEPARTMENT OF HEALTH
1.LOCATION OF WEM Count Name WATER WELL RECORD MINNESOTA UNIQUE Sam WELL NO. /I 3 8 ^ 6 r
County i for Wafer Sample [�s{1 iD,(!`f'TI t
Minnesota Statutes I56A.01-.08 '
Township Name I rwrship Number Range Number I Section No. I Fraction 4. WELL DEPTH(completed) Date of Completion
1/4
F VNW F•'_ or or
W a'',.' ...F�J (l. =c.. pi' •.F�
Distance and Direction from Road Intersection or Street Address and City of Well Location 5.DRILLING METHOD
10 Cable tool 40 Reverse 70 Driven 100 Dug
Show exact location of well in section grid with'X." Sketch map of well location. 20 Hollow rod 50 Air 80 Bored 110
M
Addition Namezo Old ; :GRotary 60Jetted 90 Power gauger
r- t-
-1 6.DRILLING FLUID
Block Number +R.if
W i ; I E 1
i Domestic 40 Monitoring 80 Heat Pump
1 i
'12 Lot Number r 20 Irrigation 50 Public 90 Industry
m:. 1
� � 1 30 Test Well 60 Municipal 100 Commercial
70 Air Conditioning 110
mile's i !' HOLE DIAM.
2.PROPERTY OWNER'S NAME i I� f HEIGHT:Above/Below
f 10 Black eldeded '
Surface (t.
;J -�N�. ►..___„ ten` 2❑Galv. 50 elded
Address /, .. �`�t�Tx �;p ,.,f �y,tY Drive Shoe? Yes— No--W--
26>
o W4
26> U”.. t&.Y �"'Y Rd* U sic 60
.,t
r
j.! Zi•�' 3 roi'J °-. 14 in.to ft. Weight :aJ$ `f06./ft. in. tort.
3. F MATION TO
FORMAS ON g
LOG COLOR HARDNESS OF FROM in.to ft. Weight lbs./ft. —gin. tort.
•-•
in.to ft. Weight lbs./ft. in. tort.
? 9.SCREEN Or open hole
from ft.to. ft.
Make
y.9•, Type "A11"ALUM& Itefil Dis.Md lei
Slot/Gauze �' Length 1 J
I ,. FITTINGS:
`.a}'r al
Set between ft.and ft.
• 4 10. STATIC WATER LEVEL
blue Ned
t p�j ft.LD below ❑above Date Measured ��t+(y� �
Ian surface
yell L-.11
11. PUMPING LEVEL(below land surface)
elw -4 ici 4 i s,'`y ft.after ii hrs.pumping L'iL 9-P in
ft.after hrs.pumping g.p.m.
°✓ ida�.il� rtP-�xra L 12. HEAD WELL COMPLETION
10 Pitless adapter.manufacturermodel
1 2b Basement offset 3k At least�l2"�above ground
.4iifir 'Tavel li 't blUi e(, 40 Plastic casing protection
-} i 4 13.WELL GROUTED?
d.
ikht f'J f 4 p Yes ❑No
10 Neat Cement 20 Bentonite 30
-- �` -- -- , 6Grout material froml U._to 'A ft.cu.yds.--
urk ILL.;-
14. NEAREST SOURCES OF POSSIBLE CONTAMINATION
feet direction type
Well disinfected upon completion? LVes ❑No
Vel ig,a. o-,. :. ..... +� t3h15. PUMP
Date installed 7'3/e,•1.''-'? ❑Not installed
- - - Manufacturer's name—
. ..-.,__. .._ __ ... . ..c
Model number .. HP_,_,•_�Volts
--- -- _ ` Length of drop pipe 126- ft. capacity g.p.m.
4 Material of drop pipe wvc
�..__ ___— - +• Type:10 Submersible 30I.S.Turbine 50 Reciprocating
20 Jet 40 Centrifugal 60
16. EXISTING WELLS
Unused well on property? ❑Yes f1 No
Use a second sheet,if needed a.
17. REMARKS,ELEVATION,SOURCE OF DATA,etc. Abandoned ❑ Permanent 0 Temporary❑ Not sealed
18.WATER WELL CONTRACTORS CERTIFICATION
This well was drilled under my jurisdiction and this report is true to the best of my
knowledge and belief.
•C,• `Li`tenser 'nd3-Near da •-
r
Signed Date
Authorized Representative
Dat
Azi Stevemg Name of Driller / 7
438460 7/7630M
LOCAL COPY 7/7830M
HE-OI205-02(Rev.10/85) 2/82 10M