Laserfiche WebLink
` - � <br /> WEL�LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> �a���Y .;,� WELL AND BORING RECORD � y� <br /> Minnesota Statutes Chapter103! � � � U � � <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> n. <br /> v. v, i. <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> i i Cable Tool ❑ Driven ❑ Dug <br /> J Auger �Rotary ❑ Jetted <br /> Show exact location ot well in section grid with"X". Sketch map of well bcation. C _.___ . <br /> Showing property lines, -- ��- - <br /> _- _ � roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �10 <br /> N f• <br /> i i i i �(j,.i� �IIB��C .FROM ft.to___ _—fl. <br /> i l i -i • <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> i i � i �Domestic <br /> _i_ _�_ _i_ _i_ ❑ Community PWS [�7 Indusiry/Commercial <br /> i i i � �.�,,,,V.,,..____---- ._ Irrigation ❑ Noncommunit PWS <br /> w E - 'X ❑ Erniron.Bore Hole Y ❑ Remedial <br /> � � � i T „��...�• ❑ Dewatering ❑ <br /> i i i i +zIM1e �'..' CASWG Drive Shoe? �Yes ❑ No HOLE DIAM. <br /> _i _ i_ _i_ _,_-, � � fi�Steel �Threaded ❑ Welded <br /> i- i i i <br /> �7 Plastic ❑ <br /> �-1 Mile-� �� <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME �__m.to��_k. _�_�__ Ibs./ft. �__in.�o___�l� <br /> in.to__ ft. _._- -- Ibs./tt. ��in.�o_� <br /> Property owner's mailing address if different than well location address indicated above. ____. in.to R. __ Ibs./ft. '4 ' ,to <br /> 27� Market �1� Ote 1J9 SCREEN OPENHOLE <br /> �,�r C n Make from fLro_ ft. <br /> Minneapolis, i'31Y )S�V� Type_ ___ _Diam. <br /> SIoUGauze Length_ <br /> Set between ft.and ft. FITTINGS: <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME __���_______ft.�below ❑ above land surface Date measured � 1_'t 9� �f <br /> �1—iJ 4 . <br /> PUMPING LEVEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. ______�3.�____ft. after._ __�_ hrs.pumping L�g.p.m. <br /> WELL HEAD COMPLETION Qhi t ewa t e r <br /> ❑ Pitless adapter manufacturer _ __ _ Model <br /> ❑ Casing Protection _ __ ____ ❑ 12 in.above grade <br /> . Cl At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? ��`/Yes ❑ No <br /> HARDNESS OF Grout Material Cl Neat cement ❑ Bentonite CJ Concrete �High Solids Bentonite <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO <br /> from___�._.to_��R _ __�_ ❑ yds.�bags <br /> Y � from__ to tt. � Y�.� ba9s <br /> cla e1ZoW sofr � from ��o ��-h. n��� � ba 5 <br /> NEAREST KNOWN SOURCE OF CONTAMINATION � <br /> clay �r$y $�f�,` 2 t� __--feet _ _ direction ____ ._type <br /> Well disinfected upon completion7 es ❑ No <br /> sa�� �j�ay 5��� 9 13 PUMP <br /> [I Not installed Date installed 11'G V`V 2 <br /> �l�y �jra� medium �J 23 Manufacturer'sname _��_@_� <br /> �� �y+� Modelnumber_________. _. __ _ ___ HP _..__�_ Volts __�_�___ ��,. <br /> fine .g��� gray ��d�U� 4.7 Z� Lengthofdroppipe t r,R _ ft. Capacity _ ____ ___gpm. <br /> / Type: ❑ Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> elay/rocks r8 mediu�e 2`� �� ABANDONEDWELLS <br /> i p p Does property have any not in use and not sealed well(s)? C Yes o <br /> g�.nd.�tOn� ra il8�d �v �v VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes f o TN# <br /> WELL CONTRACTOR CERTIFICATION � <br /> Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. �� <br /> REMARKS,ELEVATION,SOURCE OF DATA,et0. The intorm�tion contained in this report is true to the best of my knowledge. <br /> Drone casing 38Q-382 -�oir�����s�,�N�}��rf3�-f��w��.� 172 <br /> A�, ¢ RepreS ta roe Si tur ` � � 'D����- <br /> _ . _�112��1'�DC3t-�#,. 1 1—iT�_(1� f <br />��- � Name ot Driller Dale <br /> LOCAL COPY � 7 ��9 5 HE-01205-07(Rev.7J99) <br />\ IC#140-0020 <br />