HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELL RECORD � 5 3 5 6 3 4
�.�;.. �;r� Minnesota Statutes Chapter 1031
Township Name Township No. � Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
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Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
� { C Cable Tool ❑ Driven ❑ Dug
, � r r ' i;b ❑ Auger �J Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
ry �` � roads and buildings. DRILLING FLUID
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i � � � � ,USE Domestic ❑ Monitorin � Heating/Cooling
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W i ; i E ❑ Irrigation ❑ Public ❑ Industry/Commercial
_1_ _i_ __ __ T ❑ Test Weli ❑ Dewatering � Remedial
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f-mi ��,° CASING Drive Shoe? ❑ Yes Q�,Na HOLE DIAM.
--;- �- � -�' I �� � ❑ Steel C Threaded ❑ Welded -
1 Plastic ❑
~—I milr�—� �" 1 �
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CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME C-�__in.to_���ft. �bs./R f�in.to'�'�!; ft.
. ���....{ l � �y �a�..:.� in.to ft. Ibs./R �in.tq�_�_~fl.
Mailing address if different than property address indicated above. in.to ft. Ibs./ft. - in.to tt.
SCREEN OPEN HOLE -
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J; � ��� ,�. (_.:,� : . � � . . . ,. Make—z� �y,i,C��^ from ft.t ft.
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Type << Diam.
SIoUGauze /� Length t
.. .~�., . ,_. 1�� ,:--. :, �� �.,,; ."," � � � Set between ��� ft.and�_��'�_ft. FITTINGS: 5_� t� ��a e J F� .
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STATIC WATER LEVEL
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO �
MATERIAL ��� ft�below ❑ above land surface Date measured�
PUMPING LEVEL(below land surface)
(` t=` , ��r v, Y�\ �,, � j� � � 'a ft. after �„ hrs.pumping �, g.p.m.
WELL HEAD COMPLETION . t: :
�� 1 �,4 �t. y�, f � �l� t+j,. �l Pitless adapter manufacturer�v'�..,���. �n)��P�' Model tl �X ��a
� ❑ Casing Protection �1 12 in.above grade
( �..^ j � '_���.�,� ,,,�,C ,. y.,ti ���{j I�(,� GROUTINGINFORMATION
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� � Well grouted? �] Yes ❑ No
r- �` `f � w�+ � ��� ��� Grout Material ,Q Neat cement �l Bentonite`
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_ from_�__to �(� ft. i _� yds. ❑ bags
i , , from to ft. C] yds. ❑ bags
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�,..J.�... t€' � =-,b^!i �C�,� �>t� �y..� from to fl. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
�}( � feet �'� direction r�'..•'-"�,�•�[ type
Well disinfected upon completion? �7 Yes ❑ No
PUMP
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❑ Not installed Date installed ,- iq,:�_ �}
Manufacturer's name ��i�,r y+'�,� � i
Model number HP�____ Volts �j�
Length of drop pipe��� ft. Capacity /1.g.p.m.
Pressure Tank Capacity��? !f �.��, (
Type:�1 Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
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� ABANDONED WELLS ♦
Does property have any not in use and not sealed well(s)? ❑ Yes � No
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Use a second sheet,il needed •,_`•;�, ��r�. 4� /�,.J
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REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No.
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/'�� � '�� � Authorized Representative Signature ~Date
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Name of Driller Date
Laf:AL CQe'°� � � � � � ,� HE-01205-04(Rev.5/92)