|
._--�. _ . _
<br /> �. -�. .:y.�. . ..
<br /> � MINNESOTA UNIQUE WELL
<br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO.
<br /> CountyName WELL AND BORING RECORD �] r� (�}
<br /> Minnesota Statutes,Chapter 1037 t �V� �✓ �
<br /> Township Na Township No. Range No. Section No. Fraction WELUBORWG DEPTH(completed) DATE WORK COMPLETED
<br /> ��8 4.7 �! % Y<': � � n �an
<br /> GP DRILLING METHOD
<br /> LOCATION� Latitude degrees minutes seconds
<br /> Longitude degrees minutes seconds ' i Cable Tool ❑Driven -,��.Dug
<br /> L)Auger [�iotary .���.Jetled
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number �,
<br /> '+�+'�� �� �� 55356 DRILLING FLUID -�: ��WELL HYDROFRACTURED? U Yes � o
<br /> Show exact location ot well/boring in section gri with"X° Sketch map of well/boring location. ��l� Rom,_ ft.To ft.
<br /> Showing property lines,
<br /> N ` ��-�� ro s,buildings,and direction. USE ��a�
<br /> ` L�7+uomestic [�Monitoring ❑Heating/Cooling
<br /> �. __L____1_____�__ __[__ , ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial
<br /> ❑Community PWS '�'�Irrigation 'i�Remedial �
<br /> --+—--;-- ---`-- ---`-- � �Elevator ❑Dewatering [ � �
<br /> . W , , � E � _— CASWG MATERIAL Drive Shoe? Ye � HOLE DIAM �
<br /> � �rh [—� s [�IdVa
<br /> T y� Steel I Threaded ]Welded
<br /> � � � � � Mile ,_�
<br /> .. , ; , , i �lastic . ,
<br /> --,--- ---�--- ---�----%- 1 —
<br /> 1 I ' -' .�.,�,,,.,,.. CASING
<br /> g � Diam er Wei ht Specifications
<br /> �i Mae� � in.to 192 ft. ��� Ibs./ft. �� � in.lo � ft.
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. ____IbsJft. �in.t� ft.
<br /> ����('g�'�� �� in.to ft. Ibs./ft. in.to ft.
<br /> �tw
<br /> SCREEN OPEN HOLE
<br /> Property owner's mailing address if different than well location address indicated above. �
<br /> Make ��:'�� From ft. To tt.
<br /> Type����� "�"� Diam. t
<br /> SIoUGauze__ � � Length r�i '�' �i�
<br /> Set between�_ft.and__ ���ft. FITTINGS_ ��
<br /> STATIC WPT�R LEVEL
<br /> I4 Measured from��
<br /> V
<br /> ft.j�elow ��Above land surface Date measured
<br /> WELL OWNER'S NAME/COMPANY NAME PUMPIN�L€VEL(below land surface) �+
<br /> � ft.after � hrs.pumping �� g.p.m.
<br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION {� .{.
<br /> �itless/adapter manufacturer l.�t_5���..s��^-Model
<br /> 'Casing Protection ���in.above grade
<br /> ���,At-grade(Environmental Well and Boring ONLY)
<br /> . GROUTING WFORMAT��I/ON
<br /> Well grouted ,ares ❑No
<br /> Grout materials �Neat cement ',�entonite ❑Concrete ❑Other
<br /> � ���' - From�To__�R. � �Yds. [�ags
<br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_�To�Q7 R. ��_�x�. �-��,Bags
<br /> � MATERIAL From To fL ❑Yds. �_J Bags
<br /> NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> 1h .. .� ..._. ,
<br /> ' . �`�___. -_. . .� � ��� V � �i�ti.:� feet �� direction - _."-i\'i_._�.,_ tyPe
<br /> Well disinfected upon completion? ;�es ❑No
<br /> ' -C�.:_.�..._.. .. . . .�iC �l6 � � PUMP
<br /> ; . .. _.._.__ .. . '�� (
<br /> �Not installed Date insialled �` 1 i! •J"�.�J
<br /> ��e _ � _. y� g � ,
<br /> .��...-_.._..__, b��_ . .�1� ��9 Manufacturer's name l../�-�✓r'�"'���""" +
<br /> : . , . . . .._.. t ���/olts �
<br /> __.,. , _ .._.., . �-� � Model Number HP ��
<br /> -�� . �...._._......... _...._...._...___.._.,_........_.. ., - } t1'"7 :
<br /> - � - . . . Length of drop pipe ! 7 l ft. Capacity g.p.m.
<br /> �' � --- � �- -��-- � � Type: ubmersible '��`.LS.Turbine [;Reciprocating [�Jet �� �
<br /> �_; . ----._.. _.._._�..._.�......._.... ..__-..,, . ABAN ONEDWELLS
<br /> - -� �� Does property have any not in use and not sealed well(s)? ' ��Yes ,�lo
<br /> . __� ...w_..._,...,._.._.._.,..._ .
<br /> . ........... ._ —
<br /> .. .. ..,,, _ VARIANCE
<br /> � Was a variance graMed from the MDH for this well? �__j Yes �o TN#
<br /> � . WELL CONTRACTOR CERTIFICATION
<br /> . � � This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
<br /> � � � � The information contained in this report is true to the best of my knowledge. ;
<br /> -� -�-•--..�__...____.__�___._� Us�g,a second sheet,if needed.
<br /> ,..
<br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. � J� gt�� �eZ1 n�32iin� cc,,, i�• ;�I
<br /> Licensee Business Name Lic.or Reg.No.
<br /> '! � ��33
<br /> -- �
<br /> C �tiv i natur_ Certified Rep.No. Date �y
<br /> 760609 � �°�
<br /> LOCAL COPY ---
<br /> Name ot Driller
<br /> IC 140-0020 He-oi2os-ii(aev.aio�)
<br />
|