2016 - Well and Boring Construction record

Home Browse Search

. r ,41; MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING Na County Name WE L AND BORING CONSTRUCTION RECORD �� '• Minnesota Statutes,Chapter 1031 821940 nship Name wnshipNo. Range No. Section No. Fraction '1 ` WELL/BORING DEPTH(completed) DATE WORK COMPLETED Lona��o jig 013 3(l S 'I 'i 7 ea 4 n 94ok, GPS LOCA ON—decimal degrees(to four decimal places). DRILLING METHOD 5/l� S9 5 g 0 Cable Tool Driven Latitude on etude 93 3y y � ❑ ❑ ❑Auger ❑Rotary House Number,Street Name,City,and ZIP Code of Well Location Othe�hiey ' i-,., DRILLING(�acy 2 e.-6, &/a0/ 14AV' Oro c76 DRILLING FLUID y WELL HYDROFRACTURED? ❑Yes No Show exact location of well?'oring in section grid with"X." Sketch map of well/boring location. idale,` From ft.To ft. Showing property lines, 4�/ N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling ___ _ ___ ___ P �oa ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial f4V tt ® x Community PWS ❑Irrigation ❑Remedial ❑Elevator ❑Dewatering ❑ /-1 CASV w E Q r G MATERIAL Drive Shoe? X Yes ❑No HOLE DIAM. --------I----y------L-- T : ,i00Steel ❑Threaded gWelded Miie ❑Plastic ❑ -'-- ' ` f 1 1 CASING s Diameter Weight Specifications Q � 2a7'c, ,/-id a z/ in.To 3-3/ tt.94/-/a lbs./ft. -._63-/.> a3 in.T ft �--1 Mile--( Sin ' PROPERTY OWNER'S NAME/COMPANY NAME /Q in.To3lj/() ft.70.Sg lbs./ft./L5„3-/ /f in.Try,/�ft. td ) 4 in.To ft. lbs./ft. in.To9� ft. (�JSCREEN �DYIri 31/YI OPEN HOLE Property o ner' ailing address if different than well location address indicated above. Make „eal From ft. To ft. 7,5a/4Lc,YX-tel Type 1/_5/0T Diam. /�, TC/( t&/� SIoVGauze ,30 ,5/OT Length /33n OIW, m/1/ 56-35Z0 Set between 965/„ ft.and, 3/,as- ft. FITTINGS i4 dkGr STATIC WATER LEVEL Measured from? r/yy..-4 RECEis(1 ftBelow❑Above land surface Date measured 9/ //, 47 WELL OWNER'S NAME/COMPANY NAME 'V .$Et PUMPING LEVEL(below land surface) ` CYMeJC}J'I1y' _ /�/ ft.after o.2 hrs.pumping i/30 g.p.m. ,:nroring owner's mailing address if different than property owner's address iinWed aL le2O17 WELLHEAD COMPLETION / ❑Pitless/adapter manufacturer Model C'N ❑Casing protection P'fr1.above grade O�ORONc�At-grade ❑Well House ❑Hand Pump 55/; �$ ROUT INFORMATION/ R1//JJ (specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material/(/1ahlO From 0 To..2_. / ft. /9 A Yds. ❑Bags Material From To ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR FROM TO MATERIAL Driven casing seal From Q To33/ /7_Bags � //JJ NEAREST KNOWN SOURCE OF CONTAMINATION Q,Q2 Ai/�'!L-F"c.ld 3/t - . . .• /490 feet A.4,-) directions type Well disinfected upon completion? X Yes ❑No PUMP XNot installed Date installed Manufacturer's name Model Number HP Volts Length of drop pipe ft. Capacity g.p.m. Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes X No VARIANCE Was a variance granted from the MDH for this well? ❑Yes 1K No TN# 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,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Nark / t // � STriI�2QQ5/i t . /4/05 l' Li se Business Name Lic.or Reg.No. C� ---/(4.--1....r_21/11 ,_5-m9 A0 7_/cam Certified Representative Signature Certified Rep.No. Date IMPORTANT-FILE WITH PROPERTY PAPERS WELL OWNER COPY 821940- L9r/Cr/7 7 r7uf' 1r/6/6- &ra k" Name of Driller ID#52603 HE-01205-15(Rev.8/13)