HomeMy WebLinkAboutWell info STATE OF MINNESOTA DEPARTMENT OF HEALTH
I.LOCATION OF WELL 1 MINNESOTA UNIQUE WELL NO. ^45 .
•County Name WATER WELL RECORD iV+�
495
Hennepin
Minnesota Statutes 156.4.01,08 /or Water Sample
Township Name Township Number Range Number Section No. Fraction 4.WELL DEPTH(completed) Date of Completion
N E
Orono 1 1 8N s ?'1W w ,1? _ /-"L+7 t ' 160 ii. 4/7/92
Numerical Street Address and City of Well Location or Distance frond lntersecti.^ .. 6 .DRILLING METHOD
i o— rr "': ❑Cable"tool 0 Reverse 0 Driven 0 Dug
480 Orchard Park Rd Long\ Laker Mn' 5.5 '
Show exact location of well in section grid with"X." •`' Sketch map of well location. 0 Hollow Rod 0 Air 0 Bored 0
N
I
t i Addition Name 30Rotary ❑Jetted 0 Power Auger
__r__y_ _1__1_
t I � 6.DRILLING FLUID
I
.� �_ Block Number Flarniei Ci)11k gP1
wLXtl E 7.USE
3- __1I_._.t_ -:- __ 1 domestic 0 Monitoring 0 Heat Pump
• i _ Lot Number 8 1 ❑Irrigation 0 Public 0 Industry
f•m. ^/
-_�_ ;- 1 ,oc-c `' 0 Test Well ❑Municipal 0 Commercial .
-i- - -r
0 Air Conditioning ❑
I mile---i 8.CASING HOLE DIAM.
2.PROPERTY OWNER'S NAME Mailing Address if different than property address 0 Black 0 Threaded HEIGH 41=ftelow
X��ffi indicated above. Surface 1 ft.
❑Galy. ❑Welded
Drive Shoe? Yes_No_.X
Albert Esco O 'tastic 0
4 in.to 153 ft. Weight 1 _ 9 lbs./ft. min. t __It.
3. FORMATION LOG COLOR (HARDNESS OF ••. ., TO l in.to f:. !Ce e-!:: Ibs.'f: i •� •�6 n.::
FORMATION �-"'
in.to ft. Weight lbs./ft. Win. tort.
yellow clay brown soft 0 31 9.SCREEN Or'open hole
Make Johnson from ft.to. ft.
clay & sand gray soft 31 96 Type stainless steel m.. 2"
Slot/Gauze 15 slot 4enh* FITTINGS:
sand & clay gray soft 96 142 Setbetween 'ft.and ft. 5 ft . extension
10. TIC WATER LEVEL
sand brown soft 142 160 f obelow ❑above Date Measured 4/7
land surface
II. PUMPIN EVEL(below land surfA1ce)
30
ft.after hrs.pumping g.p.m.
ft.after hrs.pumping g.p.m.
12. HEAD WELL COMPLETION
ZiPitless adapter manufacturer whtietwater Model511 451
:❑Basement,offset 0 At least 12"above ground
0 Plastic casing protection
13.WELL GROUTED? cit Yes 0 No
xO Neat Cement 0 Bentonite 0
IA.
Grout material cement from 30 to 0 ft.cu.yds.
mud & bentonite 160 _30
• _
14. NEAREST SOURCES OF POSSIBLE CONTAMINATION
50 feet NL___dirediani Sl C3P plumbing type
Well disinfected upon completion?XO Yes 0 No
15. PUMP
Date installed 4/9/92 0 Not installed
Aermotor
Manufacturer's name
Model number n HP 3/4 Volts 2 2 0
• Length of drop pipe 0015[ ft. Capacity 1 0 g.p.m. •
Material x of drosteel
Pepe
Type: d-Submersible 0 L.S.Turbine ❑Reciprocating
❑let ❑Centrifugal ❑
16.ABANDONED WELLS
Unused well on property? X7 Yes 0 No
Use a second sheet,i/needed - Sealed O Permanent 0 Temporary EX 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.
Leuthner Well Inc. 10125
Licensee Business Name License No.
Address Box 159, • Victor ' - , Mn 55386
Signed L/-''�f,i h
._ _ ,�_. /L _.. Date _
i� em4` E�zed --presentative S-5
Date
Name of Driller `
30M
/74
MINN. DEPT. OF HEALTH COPY I 495545 5 5/7430M
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