well info - Laserfiche WebLink

Home Browse Search

� < � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD � � � � � ,� f�i€?f1I1@��1i7 Minnesofa Statutes Chapter f03/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. �11��13�> _ : ., = f, ��C �.; .�: �i, i. v. li:i t:�- i �-�l� House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD _ , • ❑ Cable Tool ❑ Driven ❑ Dug c:�;�::� �.Gl�.'Er3.- �l3.fyW D3:1Er�.: �.�UI�E..°� �I"f. ❑ Auger ffi Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ �U ��,U�`1` t�<<`w Showing property lines, roads and buildings. DRILLING FLUID_ N �ri?..4�;Fi�.t.z, � � � � -; -,- -;- -,- USE O Monitoring ❑ Heating/Cooling � i � i X �Domestic �� -�� ❑ Community PWS ❑ Industry/Commercial _I_ _J_ _L- -I_ ❑ Irrigation ❑ Noncommunit PWS i i i i Y ❑ Remedial yy E T ❑ Test Well ❑ Dewatering ❑ i � i i i i i _� I CASING Drive Shoe? ❑ Yes �lo HOLE DIAM. VZrn��e _i_ _ �_ L _i_ I ❑ Steel ❑ Threaded ❑ Welded � , � � 1 . �Plastic O s �-1 Mile--i CASING DIAMETER WEIGHT � PROPERTY OWNER'S NAME ' in.to �JG ft. �.�'' Ibs./ft. f �1y�.ie .::K. t:C)�'1jj Vi'�;'� in.to ft. Ibs./R. in.to ft. Property owner's mailing address if different than well Ixation address indicated above. in.to ft. Ibs./ft. in.to_tt. ��' SCREEN OPEN HOLE � � � �� c i:�.;r Make �C' �'�'�'�� from ft.to tt. i�cxic� 7:��?�.e, R'lt�. ..__:�f� Type :3�.c31P1��'d �J�E:E�. Diam. �. ,� SIoVGauze �y�,!7�� Length t} \ �j;> > Set between �c•�� ft.and ry FITTINGS: � �� 4`'% �� • ' —r�z— —�T:; STATIC W TER LEVEL WELL OWNER'S NAME ��-'r ft. E?below ❑ above land surface Date measured �3--}�__� PUMPING LEVEL(below land surface) Well owneYs mailing address if ditterent than property owner's address indicated above. tt. after hrs.pumping �-�� <i�-��'g.p.m. WELL HEAD COMPLETION �,��itc�k.�er O�Pitless adapter manufacturer Model ❑ Casing Protection L5 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? Q'3'es ❑ No HARDNESS OF Grout Material ❑ Neat cement O Bentonite ❑ Concrete �'4iigh Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO „ from �'to -%�� ft. �'❑ yds. C�1bags �.�.�2�� Gx,�� ;a '�� from to ft. ❑ yds. ❑ bags from to ft. ❑ yds. ❑ bags NEARES NOyyjJ SOURCE OF CON�AMINATION t! S.. �, � ��.c��Jf i�:3"K1 �.?r:t"h �iK' '�' � 1 L.�• �I ra� - — feet � �+t.+ � �+� direction `�-'� f�''• ;� type Well disinfected upon completion? Q Yes ❑ No CI<;�y F'+�ic;iizsii L�r;.ff.��i f�l 1�'; 7�;: PUMP �,.._��S-�i�� ❑ Not installed Date iRctalled � .- ttf A' :�,3T�Kl (iY�� :i ��.r'1 L!ri..'-F Ma�ufecturer's namq _ . G� Model number � ��"'� HP Volts `�'��' Length of drop pipe �'%� ft. Capacity 4 i: g.p.m. Pressure Tank Capaciry ��i� -�`��;I Type: �'Submersible ❑ L.S.Turbine� ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes CJ�lo VARIANCE Was a variance granted from the MDH for this wetl? ❑ Yes q�Jo WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF The information contained in this report is true to the best of my knowledge. L�C.;�d :;`z;?�;.Lt'� t"�F51. I�RI:�i_IT� t,'t�=., :tl�. �:'il '1. ��g 2 O 1997 � Licensee Busines Name �. Lic.or Reg.No. '� t�--i u--9 �-�'-� =� �. �'��. C}SY OF�RONQ AuthonzedRepresentahveS�gnature Dafe �:i:t:�: tu_x�� —i�—�� `-, k� rt.: �. Name ol Oriller Date F- }� �_ . . � � � `�.� F>> '�a .� ��:✓ � HE-01205-05(Rev.1/95)