Laserfiche WebLink
WELL L(ACATION10 MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 4 <br /> Minnesota Statutes Chapter 1031 <br /> Township Name Towpship.No. Range-No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> f. <br /> T. <br /> F1 Cable Tool El Driven ❑ Dug'Et 'iatt-i :tow. f oacj Orono, i . ❑ Auger F7 Rotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID <br /> N <br /> I I I I <br /> USE ❑ MonitoringEI <br /> C),Domestic Heating/Cooling <br /> ❑ Community PWS ❑ Indust /Commercial <br /> ❑ Irrigation <br /> El El <br /> PWS Industry/Commercial <br /> w e El Test Well y El I I I I ❑ Dewatering El <br /> -r YZMae CASING Drive Shoe? ElYes EINo HOLE DIAM. <br /> ❑ Steel ❑ Threaded ❑ Welded <br /> Plastic ❑ <br /> FI Mile <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME ( i ty'" 1 ' <br /> in.to ft. lbs./ft. <br /> —In.to_ft, <br /> in.to ft. tbs./ft. t ihl.io'_ift. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. _ lbs./ft. in.to ft. <br /> u C; -S'kiwid*`cai'i a R oac SCREEN OPEN HOLE <br /> Corcoran, MND 55314 Make „ from ft.to ft. <br /> Type Diam. <br /> Slot/Gauze I f I Length <br /> Set between + •' ft.and i ! ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME ft. below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. - ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION it•:�:t�.ii-F I.E?3:' <br /> R Pitless adapter manufacturer Model <br /> ❑ Casing Protection E3 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ❑ Yes ❑ No <br /> HARDNESS OF Grout Material 11 Neat cement Bentonite ❑ Concrete [I High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from to ft. e ❑ yds. bags <br /> from to ft. ❑ yds. ❑ bags <br /> from to ft. ❑ yds. ❑ bags <br /> NEAREST KNOWN))SOURCE OF CONT� ,/vtpTION_ - } <br /> <•-I i f,; .. ,. I, feetr�•• /J> direction , type <br /> Well disinfected upon completion? ❑YBs ❑ No <br /> C .V-'Gr avkal 1;.'Cey;°t": PUMP <br /> ❑ Not installed Date installed -'L <br /> Manufacturer's name Red Jacket <br /> Modelnumber " tC '°(` HP Volts 136 <br /> Length of drop pipe 10 BC Capacity 1(1 g.p.m. <br /> Pressure Tank Capacity #L fi —T r o l <br /> Type: [),Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑ Yes ❑'No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes El'No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> 1r`Tcf! Ct.i.. 1..i <br /> ILicenee Business Name Lic.or Reg.No. <br /> Authorized Representative Signature Date <br /> Name of DrillerDate <br /> LOCAL COPY 15889il HE 01205-05(Rev.1/95) <br />