|
* ,
<br /> WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
<br /> CountyName t;�nr��.-,,i� WELL AND BORING RECORD � 9�� -� �
<br /> , Minnesota Statutes Chapter 703!
<br /> Township Nar.�� Township No. Range No. Section No. Fraction WELL DyEPTH(completed) Date Work Completed
<br /> ��.7 C�.(..1 Z � I� 4� �.,!�2 1 ��.r t fl. � � ' � c_' . .
<br /> /. Ya V�
<br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
<br /> 4�! %`,� SO:'i�I'�,�'� Lar��* Q�C?IlCJ� MIl. . � � `�f' ❑ CableTool ❑ Driven ❑ Dug
<br /> ' ,;;�_
<br /> ❑ Auger �'Rotary ❑ Jetted
<br /> Show exact location ot well in section grid with"X". Sketch map of well location. ❑
<br /> ��`AS�,t,. / �` Showing property lines,
<br /> /��G�� � G.. roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES NO
<br /> N �+<ter.
<br /> , , , , FROM n.to n.
<br /> -,- -;- -,-- -,-
<br /> USE ❑ Monitoring ❑ Heating/Cooling
<br /> i i � i C3�Domestic
<br /> _i_ _�_ _�_ _i_ �� ❑ Community PWS ❑ Industry/Commercial
<br /> i � i i X ❑ Irrigation ❑ Noncommunit PWS
<br /> w E T ❑ Test Well Y ❑ Remedial
<br /> i i i i ❑ Dewatering ❑
<br /> i i i r +ZIM_ie CASING Drive Shoe? ❑ Yes o HOLE DIAM.
<br /> _i i � i_ I ❑ Steel ❑ Threaded ❑ Welded
<br /> ; -;- -, - -, 1
<br /> C�P�asci� ❑
<br /> s
<br /> �-1 Mlle-�
<br /> CASING DIAMETER WEIGHT
<br /> PROPERTY OWNER'S NAME � 1�3 ���.�� 1 r;Ey _3 t�
<br /> in.to ft. _ Ibs./ft. in.to ft.
<br /> �����i E`t�i(:.�.�Fsi;� �'��;i'rc3iiSf
<br /> �t. in.to ft. Ibs./fl. �_�����__�_�_ i 1 .
<br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft.
<br /> ��Z �I�t� 7�tI� St-��G�L� W��'�- SCREEN •r..t,,,,...,_.,._ OPENHOLE
<br /> Ed�Tl Pr�irie, A'IIII. �a�1�� Make � from n.to n.
<br /> Type_ � "i' `��� iam.
<br /> SIoUGauze �3 Length
<br /> Set between 1�� � ft.and�j[. FITTINGS: 3 �
<br /> STATIC IAMfiER LEVEL j �r'+,� � � �
<br /> � /
<br /> WELL OWNER'S NAME ft. ❑�elow ❑ above land surface Date measured
<br /> PUMPIN�LEV�L(below land surface) i�. ;��,
<br /> � Well owner's mailing address if different than property owner's address indicated above. ft. after 2 hrs.pumping J g.p.m.
<br /> ,WELLHEADCOMPLETION ���,��$,����
<br /> '�J Pitless adapter manufacturer odel
<br /> ❑ Casing Protection C�12 in.above grade
<br /> ❑ At-grade(Environmental Wells and Borings ONLY)
<br /> GROUTING INFORMA[TION
<br /> Well grouted? ❑�Yes ❑ No }� }�
<br /> HARDNESS OF Grout Material ❑ Neat cement `0 Bentonite ❑ Concrete L7'Hi h Solids Bentonite
<br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �r' 9
<br /> from L- to�ft. _ 1',�� ❑ yds. �a bags
<br /> Clay B12iC7�C :': t' ,, from to ft. ❑ yds ❑ bags
<br /> from to ft. ❑ yds. ❑ bags
<br /> ���v ����t�� � �; �� $JEA (NOWN SOURCE OF C MINAT�/} r
<br /> "i 1 feet �U41 J ("� !
<br /> direction���rype
<br /> Well disinfected upon completion? ❑ Yes ❑ No
<br /> Cldy Grey ' 1t ` £i_ `
<br /> PUMP
<br /> *a���� ��+�� � (� i j � t❑ Notinstalled Dateinstalled 1l�6���
<br /> Manufacturer'sname �2C� JFEC�L�t
<br /> c.I<�y—Gr�3v�1 Brc�s�n S 1 � � 1� �lodelnumber 150CNS2--CNS�A��,� 1.5 �o��s 230
<br /> Length of drop pipe 1`�� ft. Capacity Z� g.p.m.
<br /> �...'�'Cs1C.Y �I�c3.f�2 .. ��! � �rJ �Type: Submersible ❑ LS.Turbine Cl Reciprocating ❑ Jet ❑
<br /> ABANDONED WELLS ��y
<br /> C.C�i3�.�"1� r'il k.E.'.C� :] 1 fy:' p ��l boes property have any not in use and not sealed well(s)? ❑ Yes CTIVo
<br /> VARIANCE
<br /> Was a variance granted from the MDH tor this well? ❑ Yes ❑�lo
<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 /> I�t:�I� f�'1'GI7(�.i.�1 WELI, DRILLING CC. , 1ItiC.
<br /> Licensee Business Name .Lic.or Reg.No. L� J�.
<br /> �--_.... /' '
<br /> l �'
<br /> �,..� �'..+�"- _�.
<br /> � �r
<br /> ��� Authorized Representative Signature Date
<br /> �`r�.c+ Leiby 11-12-9'�
<br /> Name of Driller HE 01205-06(Rev.9/96)
<br /> L���L ���Y � � E7� � �
<br />
|