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HomeMy WebLinkAboutwell info STATE OF MINNESOTA DEPARTMENT OF HEALTH 1.LOCATION OF WELL IWATERWf4.L REGARD MINNESOTA UNIQUE WELL NO. County Name//_J l _f"teH--74,,,, " Minnesota Statutes 156A.01-.08 for Water Sample 477415 . Township Name / Township Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion E f 11.-�tn^-gr 1 / 7 1 .),3' or 3 i wt . -V+4,1,e se / I/s-- ft. 7— 3 9/ Numerical Street Address and City of Well Location or Distance from Road Intersection. 5.DRILLING METHOD CICable"fool 0 Reverse ❑Driven 0 Dug Show exact location of well in section grid ith"X." ? Ske h map of well location. 0 Hollow Rod 0 Air 0 Bored ❑__ N t Addition Name RRotary ❑Jetted ❑Power Auger -_ .__y_ _1-_1_ ' t t t A. 6.DRILLING FLUID 1 W i i_ E I Block Number 7. USE t - - I w,,,..�._- __ ..... i4Domestic 0 Monitoring 0 Heat Pump I Lot Number ❑Irrigation 0 Public 0 Industry mi ❑Test Well ❑Municipal 0 Commercial ` - - -r- ( ,� f .,/ 0 Air Conditioning 0 - £'; I--1 mile 8.CASING HOLE DIAM. 2.PROPERTY OWNERS NAME Mailing Address if different than property address ❑BlackHEIGHT:Above/Below ,fir ❑Threaded : ::. indicated above. Surface ft. ❑Galy. 0 Welded /`/• Drive Shoe? Yes_No .w-/ i ,t-/.j/�"+ I 'Plastic ❑ ,. '1+" tl in.to /If/ft. Weight—144„t._lbs./ft. -en. tort. 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight lbs./ft. 4-in. tc Ft. FORMATION in.to ft. Weight lbs./ft. _in. to_ft. %' '' /.....) 0 Y3 9.SCREEN Or open hole 1 1 �=�t rt----1 i Make ..r"^.-•• from ft.to. ft. �^ fifr/' / �j f _ /' f r dCR'-----. / e r '7 ? I Y Type _.41.e .--.kiL.a-+ .. r�! Diem. J L. / Slot/Gauze f) Length t; FI4INGS: ..zet-^.-e• `j (.. _..d�-ill � 1�.�t_!.-.x. f �� f✓!f Set between t of (t.and r r! j(i. ✓J I{ 10. STATIC WATER LEVEL .1.1�1--4)"--41 req - (-17"-'1..1.1 j,/f / 1/i— 4--j fL below ❑above Date Measured 7 ., GI. r;/ lasurface II. PUMPING LEVEL(below land surface) Sl ft.after f hrs.pumping ,y) I— g.p.m. ft.after hrs.pumping g.p.m. 12. HEAD WELL COMPLETION f Witless adapter manufacturer Model d - '/ . I '❑Basement,offset ❑At least 12"above ground ❑Plastic casing protection 1 r " cm I3.WELL GROUTED? Yes 0 No nr3nran ��w//7M L ) Cleat Cement ❑Bentonite ❑ `' `---'`---� Grout material from 5 0' to C) ft.cu.yds. . 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION AUG 5 1991 6 0 feet .s 4.. direction -1 . .._.. /4'172, x. Well disinfected upon completion? ilL,Yes ❑No4,-. 15. PUMP Date installed 0 Not installed Manufacturer's name Model number HP Volts Length of drop pipe ft. Capacity _ __ _--g.p.m. Material of drop pipe Type: ❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet 0 Centrifugal ❑ 16.ABANDONED WELLS Unused well on property? Nes 0 No Use a second sheet,if needed Sealed Permanent 0 Temporary 0 Not sealed 17.REMARKS,ELEVATION,SOURCE OF DATA,etc. • 18.WATER WELL CONTRACTOR CERTIFICATION This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief. 7 4. Licensee Business Name }f/�' j License . Address t/ _I' ? i //• l 1 fre- ' ..f'- Signed //11L1- . -• -e•44"..6.1 . s - Date 7 . !/-4,.�f Authorized Representative '_-"fin. C7 7-1;--4,10.-- , Date 7 .. .1- Name of Drille 4 7 7 415 5/74 30M 7/76 30M LOCAL COPY HE-01205-03(Rev.9/88) z 82 t0M STATE OF MINNESOTA•DEPNRTMENT OF HEALTH • ABANDONED WELL RECORD 1. LOCATION OF WELL• MINNESOTA UNIQUE WELL NO. (leave blank if not known) • County Name i Ci1Tow,nnsshiippyNamee Towns p Num© Range ^Number Section No. Fraction h 4. WELL DEPTH�(completed) Date sealed Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known) / J Intersection 1(]Cable tool 41:3 Reverse 70 Driven 100 Dug Q Vr/ l � y7! e Aiy c 213 Hollow Rod 5❑Air 80 Bored 110 3❑Rotary 6❑Jetted 9❑Power Auger Show exact location of well (in section grid with "X") Sketch map of well location 6. OBSTRUCTIONS N -1,f Well obstructed Yes ❑ No gym=/ Obstructions removed Yes (]No If obstructions cannot be removed, contact MON -'. _ E before sealing. ( T 7. USE •• � - y.i. �/ 1KDomestic 40 Monitoring 80 Heat Loop 21:3 Irrigation 510 Public 90 Industry 3❑Test Well 6❑Municipal 1010 Commercial 1 Sit--+ Fe' J7❑Air Conditioning 11❑ 2. PROPERTY OWNER'S NAME Mailing Add different than 8. CASING(S) _ property address indicated above 1[]Black aThreaded 70 7714fi Galy. 5E1Welded 31:3 Plastic 6❑Stainless Steel HARDNESS OF 01 in. to ) 1 V ft: 3. FORMATION LOG COLOR FORMATION FROM TO If not known, indicate formation log from new well or nearby well. in. to ft. 9. SCREEN Screened well from Loft. to,LO)t. (If known) 0 Open Hole from_ft. to_ ft. 6(2 .-Le. ( I V l 7,7" 10. STATIC}HATER LEVEL ft.ig,,Qe1ow ['above ,✓?J� land surface Date Measured / 11. WELLHEAD COMPLETION 10 Pitless Adapter 4❑Found Buried 2❑Basement offset 50 W11 Pit 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. 12. GROUTING INFORMATION 1.Neat Cement 2❑Bentonite 3[] Grout material from���Oft. cu. yds 13. ' u NEAREST. SOURCES OF CONTAMINATION / Q � feet W direction type Well disinfected before sealing? Ayes 14. PUMP 423 Removed 0 Not Present Type: 1[)Submersible 3❑L.S. Turbine Reciprocating 254Jet 4❑Centrifugal 60 15. EXISTING WELLS (Please sketch locations of abandoned and active wells in remarks section or on back.) Other unused will(s) on property? I,4 Yes 0 No Abandoned: Permanent 0 Temporary 0 Not sealed 17. WATER WELL CONTRACTORS CERTIFICATION This well was sealed under my jurisdiction and this report is true to the best of my knowledge and belief. LiclAsee Busin ss Name License No. Address C ,3o t boy Signed Mfr Date 7 �`�►.f�. •..�°.. Date 7--?--e/ OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of ,r,ler IMPORTANT: PILE HITS DEED STATE OF MINNESOTA•DEPARTMENT OF HEALTH ABANDONED WELL RECORD 1. LOCATION OF WELL. M(leave blank NIQUE f of knoLwn)NO. County Name Township Name TP n r Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed N 11 E k k of k © / 1 7 Sr 4-,74). 7 i 7 p ft. 7 --I— -7 '7 J Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known) f Intersection 1[]Cable tool 40 Reverse 70 Driven 100 Dug 42 2 0 0 0 /,/ •, .1j ` ./ — Hollow Rod 8Q Bored Air 110 Show exact location of well 30 Rotary 60 Jetted 5Q Power Auger (in section grid with •X•) Sketch map of well location 6. OBSTRUCTIONS N li_:_Ti-14 Well obstructed 0 Yes ® No Obstructions removed 0 Yes 0 No If obstructions cannot be ' i ' removed, contact MOH M _ _ _ _,_ .. _I_ 1 _ E before sealing. : 1 : T v` 7. USE • .-' - 4,,,C, �,(:: *--.„,4.,......a/' laDomestic 40 Monitoring 80 Heat Loop 20 Irrigation 50 Public 90 Industry 30 Test Well 69 Municipal 159 Commercial 1---1 wiLv--•+ 1 70 Air Conditioning 110 2. PROPERTY OWIER'S NAME Mail ng Address if different than 8. CASING(S) Tr property address indicated above 10 Black firThreaded 70 (444 2®..Galy. 51:I Welded ;ti-10,/,/, ( . 30 Plastic 60 Stainless Steel HARDNESS OF in. to /o2 1— ft. 3. FORMATION LOG COLOR FORMATION FROM TO If not known. indicate formation log from new well or nearby well. in. to ft. . • 9. SCREEN A•Screened well from /24-it. to.39ft. (If known) ,0-1.7y..„4. o 7 rQ ❑Open Hole from_ft. to_ ft. 10. STATIC NATER LEVEL I, O ft. apelow 0 above land surface Date Measured 7-- 3 7 O :,.." 11. WELLHEAD COMPLETION . 10 Pitless Adapter 40 Found Buried ' 2Q Basement offset CI Well Pit 16. REMARKS. ELEVATION. SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. 12. GROUTING INFORMATION 1g Neat Cement 20 Bentonite 30 Grout material J from/J4o(ft. cu. yds 13. NEAREST SOURCES OF CONTAMINATION r 2.z.4,feet L41 direction .7., type Well disinfected before sealing? g Yes 14. PUMP 0 Removed 1GT'Not Present Type: 19 Submersible i"30 L.S. Turbine 5J Reciprocating 20 Jet 40 Centrifugal 60 15. EXISTING WELLS (Please sketch locations of abandoned and active wells in remarks section or on back.) Other unused well(s) on property? Yes 0 No Abandoned: (s(Permanent 0 Tempora 0 Not sealed 17. WATER WELL CONTRACTORS CERTIFICATION This well was sealed under my jurisdiction and this report is true to the best of my knowledge and belief. Li Bushes me 4 License Ns. Address 41—..7o �r j ' -' Jed, '9",y (140 • Signed + ..a//17.0e Date ")- )14-4!/ Date 7- .7-f/ FFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of ri frr I1lPORrAHT: PILE WITH DEED