HomeMy WebLinkAboutWell Seal Record MINNESOTA UNIQUE WELL
WELL QR[30RING LbCATION MINNESOTA DEPARTM@N7 pF HEALTH AND BOR/NG NO.
county Name Minnesota Statutes,Chap#er 103I ��� ��
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Tovmship Narne Tovdnship No. Range No. Section No. Fraction WELLJBORING DEPTH(compieted) DATE WORK COMPLETED
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GPS DflIL�ING METHOD
LOCATION: Latitude degrees minutes seconds
Longitude _... deyrees minutes seconds ��Cable Tooi �Driven �J Dug
n Auger ❑Rotary I�tted
House Number,Street Name Citg and Zip Code of Well Locaiion or Fire Number ��
^^ ' DRILLING FLUID WELL HYDROFRACTURED? Yes No
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Show exact location of v✓eil/boring in section yrid with"X" Sketch map oi welUboring location. �'j��d,�"4. From ft.To ft.
Showing property lines, --
N WG„�,�... roads,buiidings,and direction. USE --
�,= U Domesiic L)Monitoring [�i Heating/Cooling
__J___ _;.__.__�_.___L_ � , �� �,�„_ ��Noncammunity PWS �Environ.Bore Hole � �Industry/Commercial
� � 1V ��
(]Community PWS n Irrigation LJ Remedial
' - --'--- --`- `--
� � U Elevator [ ewatering ❑. __
'°'y' � , , � E� � � CASING MATERIAL � HOLE DIAM,
, � � �A �����hJ� Drive 9hoe. U Yes n No
� --�- ;--
, ; , �teel {�Threaded �J Welded
, �Mile �� � � u
-�� � � ��.,� �Plas[ic .
- �----*-
; I � � CASING
� � ���(�,� Diameter Weight Specifications
� �-1 Mile—� � ��b� '
� —f(�...._in.to—��ft. ._.�--IbsJfL _...._.......--- in.to—_._ft.
�ERTY OWNER"S NAME/COMPAN NAME in.to _ft. .......__ ibs.lft. __.__..in.to ft. I
PR 1�1 t��. ���� �, ----_in.to tL -----IbsJfL _. _ in.to....__ft.
SCREEN OPEN HdLE
Property owner's maifing address if different than well location address indicated above. ___...
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{ /�,} �y�( �t -�r� � T e �/ - �Om � fi. To____ ft. E
� !�`�b 1 U.. �6�,"�2..'�,.� �� a e y�_......._ Diam. ,(�`�,2 (
�ti�" f� iM"""° yP �y��
i ,�y�� ���'�*-� 'y SIoUGauze.... � _Length_��._.
�„1��.4�.1A��.'�r f'' r d>t. --
Set�eiween�tt.and__ ft. FITfINGS
STATIC WATER LEVEL ������
Measured from
e� ft[ elaw✓ n Above land surface Date measured
WEL�OWNER'S NAMECOMPANY NAME PUMPING LEVEL(below land surface} �
� �
ft.after hrs.pumping g.p.m.
WelVboring owner's mailing address if different than property owners address indicated above. WELLHEAD COMP�ETION '
��G �J Pitless/adapCer manufaoturer Model �
I — ,,�
f ��Casing Protection_ _ �,ar,�2 in.above grade J
E �J At-grade(Environmental Well and Boring ONLY) �� f
i �
� GROUTIWG INFOFCMATION �q;�� �
� Well grouted �Neat e�� �
Grout materials , ement �Bentonrte �f Concrete U Olher f
From To __ii. [�Yds. �Bags J
GEOLOGICAL MATERIALS COLOR HARq7NESS OF FAdM Ta From To ft. �Yds. ❑Bags �
MATERIAL From To ft. �"
❑Yds. ❑Bags �f
NEAREST KNOWN SOURCE OF GONTAMINATION I
�►A�. �r�Y�J (,3 '��► 1
feet _ direchon rype
� � Well disinfectetl upan completion? ❑Yes U No �
PUMP `
❑Not insialled Date installed
r � 1
� ' f
Manutacturer"s name ��,�_
1
Model Number �,�Cl/ HP �Volts �
Length of drop plpe-�i�_ ft. Capacity_.__�'� g.p.m. �
-
Type:[ ubmersible ❑L.S.Turbine �J Reciprocaiing ❑Jet U '
ABANDONED WELLS �
Does pwperfy have any not in use a�d oot sealed well(s)? U Yes � o �
VARIANCE �
Was a variance granted from the MDH for this weli? ❑Yes No TN# �
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true ro the besi of my knowledge.
Use a second sheet,if needed.
REMARKS,ELEVATION,SOURCE OF DATA,etc.
� � � � ���� r���►�,�.���� C:.,�� ,I.�`I��
, �icensee Business Name Lic.or Reg.No.
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Certified Representalive Siynature Cerkified Rep.No. Date
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IC 1A0-d020 riE�oi2os-ii�Rev.aia�)