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HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name t, WELL AND BORING RECORD Wepi('(�C..9 t A Minnesota Statutes Chapter 1031 610 4 5 2 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed OROh4O In t, 073 vi -2 'SF/.00 W 3 O5- a. House Number,Street Name,City,0and Zip Code of Well L cation or Fire Number DRILLING METHOD - �!�� 365 Ott[] ! O�'�4A ❑Cable Tool ❑ Driven 0 Dug ��Ll in ❑ Auger otary ❑Jetted Show exact location of well in section grid with.r. Sketch map of well location. ❑ 0 Showing property lines, roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES LO N s R�'t1.,/� Ai p + + + R7F��1O �7{ito FROM ft.to ft. i i tff� 7- USE ❑ Domestic 0 Monitoring 0 Heating/Cooling -- - 0 Community ❑ Indust PWS /Commercial , , .-" irrigation Industry/Commercial+- -+-- w + + E T 0 Test Well ❑ Noncommunity PWS 0 Remedial i 1. --r-- I ❑ Dewatering 0 1 /�w. CAilifatrSING " Drive Shoe? 0 Yes lIC io HOLE DIAM. i i .'-'4111.61:1 _ .kSeel ❑Threaded lrelded 1 ❑ Plastic ❑ S F__-,Milo--.-I Pe/4A • CASING DIAMETER WEIGHT PROPERTY OWNERS NAME (a in.to 2.7.0 ft. (p� OR lbs./ft. /bin.to t. V14 OF OROPi© in.to ft. Ibsfft. _in.to ft. Property owner's mailing(� address If different than well location address indicated above. In.to ft. lbs./ft. _in.to_ft. P.0. •.�+0 t SCREEN OPEN HOLE ��y C NISM �VZIPF.01:241 Make from a.4 0 ft, CJS ft. ��G , _1 Type Diem. VO9� 1M N 01 N r SS 3SCo Slot/Gauze Length Set between ft.and ft. FITTINGS: STATIC WATER LEVEL WELL OWNER'S NAME S 7 ft.OKbek)w 0 above land surface Date measured S 18-90 C.ry of OHO PUMPING EL(below land surface) Well owner's mailing address if different than property owner's Address indicated above. i ft. after $ hrs.pumping : /s0 g.p.m. P• , WELL HEAD COMPLETION Cl Pitless adapterrpanpfacturer Model ❑ Cesing°Protection *12In..abovegrade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? )6es 0 No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material eat cement 0 Benton 0 Concrete High Solids Bentonit MATERIAL ,t to /qo ft. 1 0 yds. bags from to ft. ❑ yds, 0 rags a kl 60 V C. sok* O to from to___0_ft. __OWL ❑ yds. bags NEAREST/+O5 SOURCE OFCO AMINAT�IONG wEWA 70 HO feet � direction PQ1141:4 type \ Well disinfected upon completion?. "%i'es 0 No •jti41 6M t 50l() 15O PUMP t ❑ Not installed Date installed S 15rhd(JRdck Bd04611,4464 Mtfit1\vM t St} 2.08 Manufacturers name G LLQ!r4 a FOS _t � Model number HP 10 Volts Lk° L.%MUGS 1O 4lL 1/AIfV 14.0.41 203 ZZO Length of drop pipe jlh ft. Capacity /35- g.p.m. LIME SR c�S sok I i�U(I4- `w Jv F� '2 S4 Type: ONSubmersible 0 L.S.Turbine ❑ Reciprocating 0 Jet 0 t ABANDONED WELLS t 2 Does property have any not In use and not sealed well(s)? 0 Yes gleNo Li N44%1-0`f &fF �L�IaRN_r J VARIANCE Was a variance granted from the MDH for this well? 0 Yes lieNo WELL CONTRACTOR CERTIFICATION Use a second sheet,If needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS ELEVATION SOURCE OF DATA,etc. The information contained in this port is true to the best of my knowledge. Business Name Lk.or Reg.No. �' I Authorized Repro; tative Signature Date I�C.N RtitiVvh�' / IMPORTANT FILE WITH PROPERTY PAPERS 610 4 5 2 Name of Driller Date WELL OWNER COPY HE-01205-06(Rev.9/96)