Laserfiche WebLink
WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> CountyName WELL AND BORING RECORD 6 2 7 2 4 2 <br /> �r'_I2YtBp�i1 Minnesota Statutes Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> rono !17 23 Z A1W,,.SW,. S�?,. 1gg � 8/26/y4 <br /> House Number,Street Name,City,and Zip Code of Well Lccation or Fire Number DRILLING METHOD <br /> 825 South BYflWA ROAa 0'LO'[l0 ❑ CableTool ❑ Driven ❑ Dug <br /> • ❑ Auger �Rotary ❑ Jetled <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ ; <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID � WELL HYDROFRACTURED? ❑YES�.NO <br /> N <br /> � � � � . ', , . ' Faonn n.io n. <br /> -,- -;- -,-- -,- �.— � <br /> �--^ � USE �^ ❑ Monitoring ❑ Heating/Cooling <br /> � i i i �F���omestic ❑ Communit PWS <br /> -�- -a- -�- -'- ❑ Irrigation Y ❑ Industry/Commercial <br /> i i i i � ❑ Noncommuniry PWS ❑ Remedial <br /> �q� E � � ^� [7 Environ.Bore Hole ❑ Dewatering ❑ <br /> i i i i <br /> i i i i +�ZM,e {. :v"'t � � CASING Drive Shoe? ❑ Yes �No HOLE DIAM. <br /> 1 � ❑ Steel ❑ Threaded ❑ Welded <br /> -'- -L- -'- i <br /> � �- � � �.a�astic •l� �Iue <br /> S �,I". �I � ,i,.,- . <br /> �-1Mile� ..' � IJ M1�-:rP_} .j t..,L 4.: ..'l <br /> CASING DIAMETER WEIGHT f � <br /> PROPERTY OWNER'S NAME � in.ro 1�� ft. Ibs./ft. -�/y in.to�� ft. <br /> Pi11�r Hc�me.s m.co ft. Ibs./ft. �m.cd�e. <br /> Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./R. in.to ft. <br /> SCREEN �"'� OPEN HOLE <br /> 740 East Lake Stre�C Make Jav co from n.co n. <br /> T �F.: @SCOp.Lt2g. Diam. <br /> Gd3yz3t�, p`��I 55391 SIoUGauze 1$ Length S' <br /> Set between ��li ft.and 1$9 ft. FITTINGS ��c3C�i <br /> STATIC WATER LEVEL <br /> WELL OWNER'S NAME S.�'.1 ft.�4 below ❑ above land surface Date measured <br /> PUMPING LEVEL(below land surface) <br /> Well owner s mailing address if different than property owner's address indicated above. ft. after hrs.pumping g.p.m. <br /> WELL HEAD COMPLETION 4, � <br /> � Pitless adapter manufacturer Model <br /> ❑ Casing Protection �9 12 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> s. GROUTING INFORMATION <br /> 1 <br /> Well grouted? C�lYes ❑ No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cemen��?-BentoniLeS ❑ Concrete 3High Solids Bentonite <br /> MATERIAL from to � ft. ❑ yds. �bags <br /> from to ft. ❑ yds. ❑ bags <br /> Clr�� Bi'orv�. � �'0 r�om �o n. ❑ yas. ❑ bags <br /> / NEAREST KNOWN SOURCE OF CONTAMINATION , �' �� +_. <br /> C�.a�/a�S1°F? CsrE'�j' r�� �i� feet direction type <br /> Well disinfected upon completion? �1 Yes ❑ No <br /> G�.:2�� �2�f;�� 4l� ��� PUMP <br /> ❑ Notinstalled Dateinstalled 3��'��d� <br /> Sand/C1ay Gray red 1t?� 13�: = y�re <br /> Manufacturer's name <br /> Model number HP t � � Volts <br /> Cl�.wt F�ecl 13i 178 <br /> Length of drop pipe 1�$ ft. Capacity ��� g.p.m. <br /> �� Siinf� :�X I7$ i�i9 Type: ❑ Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ <br /> ABANDONED WELLS t1 <br /> Does property have any not in use and not sealed well(s)? ❑ Yes Qi No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes �No TN# <br /> WEIL CONTRACTOR CERTIFICATION <br /> Use a second sheet,ilneeded 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 /> S�ev�a� �riZli-�s� � E�av• a7PJ. �T144.41 itiaSG - <br /> Licensee Business Name Lic.or Reg.No. <br /> -- ... , ��L�/oo t <br /> Authorized Representative Signature Date <br /> Ph;.�t ip Jt;c> <br /> Name of Dri/ler HE 01205-06(Rev.7/98) <br /> LOCALCOPY 627242 <br />