HomeMy WebLinkAboutwell info STATE OP MMNESO"fA UEPARTMENT OF HEALTH
I.LOCATION F WELL WATER WELL RECORD 'ti����N@'SOTA UN/QUE WELL NO. �7�3 f 4
County Name �or Wa[rr Sample
�}��� hlinnesola S1a(ufes 156A.01�.08
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Township Name Township Number Range Number Section No. Fraction 4.WELL DENTH(compleledl Date of Completion
Ur�o 11'7et s 23W w ? S6�''NE ''S��' $205�. 05/13/91
Numerical S[ree[Address and City of Well Location or Distance from Road Intersection. 5. DRILLING METHOD �
1496 Park Urive 1"J�JWii� NAt 55364 o Cable"lool ❑Reverse ❑Driven ❑Dug r`�
Show exact location o(well in section grid with"X." Sketch map u(well location. ❑Hollow ILud ❑Air ❑Bored ❑ �
N
� i i i Addition Name J�Rotary ❑Jetted ❑Power Auger
-� -� � -� ti.DRILLING FLOID
� � � Block Number ��
W --i- -;- �- �- E 7. USE
� �Domestic ❑Momtoring O Heat Nump
_1_ _S_ _'_ '' T
I ; � � f'm. Lot Number ❑Irrigation ❑Public ❑Industry
� i ❑Test Well �O Municipal ❑Commercial
'-�- �- - -r- I ❑Air Conditioning ❑
� � 1 milrr� 1 8.CASING HOLE DIAM.
2.PROPERTY OWNER'S NAME Mailing Address if different than property address ❑glack HEIGH7':Above/Below
. ❑Threaded.:. �.
indicated above. Surface tt.
❑Galv. ❑Welded
Drive Shce? Yes— No—
JO� �T..s+.�� �Nlastic e� .
tGi �y (� �}
4in.to y�T[ Weight IbsJtt. �n. td�'�t.
3. FORMATION LOG COLOR HARDNESS OF F'ROM TO in.to (t. Weight Ibsltt. —�n. to�t.
FORMATION
Y...1 1 ,�J in.to tt. Weigh[ IbsJft. —�n to�t.
G.11
C� �� � �� 9.SCREEN Or�openhole
� yT�J(� = from � tt.to. ft.
Make 77c7Y�7
� i)�� �� �� TYPe " _ Diam.�3.n• l�'.�•
�_. _N� '�+�� SIoV(iauze �v/�g/��O� � /� Length �FI 7'NGS: �
l~�T�7�t�YC:l �'(,�f1� �L 6! Set 6etween �VV fl.and ��4J� (t. �}'w� � �
C 10. STATIC WATEH LEVEL �9
^Jl^��l ,�yjj� V7 77 66 ft.j�below ❑above Date Measured,�}���,al
���h • land surfacr�
�d�} p I1. PUMPING LEVEL(below land surtacel
C� � �� �iu•�,�{� • + ��O tt.after hrs.pumping �V g.p.m.
�.7ii 1l��7 � (t.a(ter hrs.pumping g.p.m.
SGsiwt �SCIT� C� � BrCfYl�l 1�.I� 11� 1SZ �Z. HEAU WELL COMPLETION
�h �Pitless adapter manu(acturer }a�+�+� Model
C��i'_�„Y� �� �Q� y�Q O Basement,oftset O At least 12"above ground
—Vi. V 1 7 ❑plastic casmg protection
�"i� 13. W ELL GROUTEDt �Yes ❑No ;,�
Grav�1 189 205
�Neat Cement ❑Bentonite ❑ �
Grout material [rom�to�ft.cu.yds. _
la. tiFAKF.Sf SOURCES OF POSSIBLE CON7'AMINATION
(irl direction type i�
Well dfsin(ected upm compleuon7 �Yes ❑No �
�` 15. PUMP x
� 14/91 ;�
Date installed ��� O Not installid
": Manu(acturer's name �S���mt�� ��
�� Model number— —HP�:i��Volts� :�-�
�` �{�C3 (t. lapaci� 12 m. �Y
Length of drop pipe 1y1.� y H�p�
Material o(drop pipr y�r � ��
Type: �Submersible ❑L.S.Turbine ❑Reciprocaling '
❑Jet ❑Centrifugal ��
�,��� I6. ABANUONED WtiLIS
�;:
'!:i� Unused well on property? ['y Yes g[No
� Use a second shee(,!J needed Sealed '] Permanent ❑ Temporary 0 Not sealed
17.REMARKS.ELEVATION,SOURCE OF DATA,etc.
� I8. WATER WELL CONTRACTOR CERTIFICATION
This well was drilled under my jurisdiction and this report is true to the best o(my
knowledge and belief.
Ste,vens �11 7rilling Co., Inc. 27194
/.irensee Business Name Lirense No. ;.:p
Address
6240 . � Plain 1��d 5�359 �
�� � � �f
Signed -+�'""'� '"'--•--^' Uate r 3 1 �
Authorized/2�•presenm(iue
A'i1lK R1V�.Y'S .Date U5 1� �1 �„
Na me o(Dnller
47�364 5„'�M
LOCAI_ �:OPY 7/7630M
7/78 30M
HE-01205-03(Rev.9/88) 2ie2 tonn