Laserfiche WebLink
STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> t.LOCATION OF WELL1 WATER WELL RECORD MINNESOTA UNIQUE WELL NO - 1113 <br /> County Name for Water Sample T <br /> Minnesota Statutes 156A.01-.08 <br /> Township Name Township Number I Range Number I Section No. I Fraction 4.WELL DEPTH(completed) Date of Completion <br /> t72 UZX? U78 o23W. ° 33 lei'' SW,W, - 13* 'n. 10J25/90 <br /> Numerical Street Address and City of Well Location or Distance from Road IntersectitYn. 5r DRILLING METHOD <br /> 2725 W Wayzata <br /> zatidBlv -` , M 55356 <br /> 53 5` ❑Cable'lool ❑Reverse ❑Driven ❑Dug <br /> Show exact location of well in section grid with"X ' Sketch map of wepll location. ❑Hollow Rod ❑Air ❑Bored ❑ <br /> N yy <br /> I � t i Addition Name i7 Rotary ❑Jetted JtPower Auger <br /> ti.'DRILLING FLUID ` <br /> NOM <br /> l ' t I Block Number ^,, g `-'°� <br /> --+- -=- - - well Y `,8 3. 7. USF. <br /> WE t � I � <br /> ❑Domestic &&onitoring.� ❑Heat Pump <br /> ( Lot Num tx•r ❑Irrigation ❑Public ❑Industry <br /> mi. <br /> ❑Test Well {]Municipal ❑Commercial <br /> ❑Air Conditioning ❑ <br /> t 1 <br /> ri.CASING HOLE DIAM. <br /> 2.PROPERTY OWNER'S NAME Mailing Address if different than property address lack HEIGHT:Above/Ji <br /> �1 ❑Threaded <br /> Tom. indicated above. Surface 2 it <br /> vei Capital, <br /> • ❑PlastGaIv $Welded <br /> `W. Wl �e� W. <br /> r� y,� Blvd. DriveYShce? Yes_No� <br /> V VCv 356 -❑Plastic ❑ <br /> �'"'� � `�� 2 _ in.to ft. Wdight lbs./ft. Win. t, t. <br /> 3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to ft. Weight lbs./ft. in. tort. <br /> FORMATION <br /> A 2 <br /> in.to ft. Weight lbs./ft. in. tort. ' <br /> to soil V <br /> blackSCRE I Or open hole <br /> from ft.to. ft. <br /> ake <br /> clad gray 2 13 Type get s Ste-A- <br /> Diam. <br /> Slot/Gauze 30 Length �� <br /> . FITTINGS: "I_4 <br /> Set between 3 ft.and 33 ft. <br /> Y <br /> -- 10. STA IC WATER LEVEL <br /> fl.Xbelow ❑above e. Date Measured <br /> land surface <br /> 11. PUMPING LEVEL(below land surface) <br /> ft.after hrs.4umping 2 g.p.no. <br /> ft.after hrs.pumping g.p.m. <br /> I2.HEAD WELL COMPLETION <br /> ❑Pitless adapter manufacturer Model <br /> '❑Basement,offset K.41 least 12"above ground <br /> ❑Plastic casing protection <br /> I3.WELL GROUTED? X Yes ❑No <br /> Teat Cement ❑Bentonite 13' - .r <br /> yam., <br /> Grout material 1>/i 2 bin from © to 2 ft.cu.yds. <br /> 2 <br /> 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION <br /> feet direction -tp pe <br /> Well disinfected upon completion? ❑Yes IgNo <br /> 15. PUMP yy <br /> Date installed I Not installed <br /> Manufacturer's name - <br /> Model number HP Volts- <br /> Length of drop pipe ft. Capacity _.-.- ppm. <br /> Material of drop pipe -- <br /> Type: ❑Submersible ❑L.S.Turbine 0 Reciprocating <br /> 11 jet ❑Centrifugal ❑ - <br /> 16. ABANDONED WELLS <br /> Unused well on property? ❑Yes $No <br /> Use a second sheet,if needed Sealed ❑ Permanent ❑ Temporary ❑ Not sealed <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> tri.WATER WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my jurisdiction and this report is true to the best of my <br /> knowledge and belief. <br /> Stns tell Drillbig CO. 27194 <br /> Licensee Business Name license No. <br /> •- Address 59 <br /> " Signed <br /> Authorized Representative <br /> _ rrT4'7bna"m late:!-- 3_q1 <br /> Name of DHIler <br /> LOCAL COPY 1471113 7/7430M <br /> 7/76 30M <br /> 7/76 30M <br /> HE-01205-03(Rev.9/88) 2/62 10M <br />