|
arnmrccnra r rnunr rc u.c~ r
<br />
<br />WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH ---'" -"'~~"` ""`
<br />AND BORING N0.
<br /> me
<br />t
<br />C WELL ARID BORING RECORD
<br /> oun
<br />a
<br />~~ f'~ ~~ Minnesota Statutes
<br />Cha
<br />ter 1037 ~ ~ ~ 6 Q O
<br /> ~ ~ : ,
<br />p
<br /> Township Name Township No. Range No. Section
<br />N
<br />o. Fraction WELUBORING
<br />~PTH (
<br />mpleted) DATE WORK COMPLETED
<br /> ' t,Ci-(,L,'i1
<br />J i1 ~'~G ~ V ~, ~ r
<br />,
<br />~ J 4
<br />i .. ct; ~ ta,! ~
<br />)
<br />L'/ `, j' ~F' ,~ ' ~?
<br /> _ .
<br />G iv '!.
<br /> GPS
<br />OCATION: Latitude degrees __ minutes ___ seconds __ DRILLING METHOD
<br />
<br />r^ able Tool ^ Driven ^ Du
<br />g
<br /> ', Longitude-__ degrees minutes ____ seconds ~
<br />~ Auger ^ Rotary ^ Jetted
<br /> ,ou~e //Numbe~Stre t Name, City, and Zip Code of Well Locaticn
<br />~ e
<br />r
<br />orc~Fire Numb
<br /> ~~ l~ ~ i
<br />~.~r {_~J~_~ ~ j')[~_'~i~fi ~L~;',J"~I' ~ /
<br />a
<br />X15 ~`~' `/ DRILLhNGJ FLUID WELL HYDROFRACTURED? ^ Yes [~J No
<br /> Show exact location of welllboring in section grid with "X." ,,,,, _ Sketch map of wel6boring location.
<br />I ~, (\/ Showing property lines, /~/ ~ ~"~ +v From _ ft. To ft.
<br /> roads, buildings, and direction.
<br />it USE
<br />^ Domestic onitoring [I HeatinglCooling
<br />
<br />r~
<br />I I "~"~ ( ->
<br />r
<br />' ~
<br />~ !_i Noncommunity PWS [] Environ. Bore Hote ^ Industry.%Commercial
<br /> ~
<br />• ^ Community PWS 1 Irrigation ^ Remedial
<br /> --~--- -- ~--- ---~-- ---;-- ^ Elevator ^ Dewatering ^
<br /> w ; ; E ~ ~
<br />-~
<br />Lj
<br />, ~ ~ ~
<br />~ CASING MATERIAL Shoe? ~ o
<br />ive es HOLE DIAM.
<br />
<br />'f ~
<br />'
<br />i L~ St el [dreaded ^ Welded
<br />
<br />
<br />'
<br />
<br />T
<br />
<br />% Pd
<br />le StiC ^
<br />la
<br />--
<br /> -
<br />--;--- -
<br />- ---~-- ---
<br />~ CASING. _
<br /> S Diameter Weight Specifications
<br /> ~ '~•'
<br />i
<br />["~ ~~ ~7
<br />y
<br />G
<br /> ~ --i
<br />t Mile _
<br />n. to _
<br />ft. lbs./ft. __,__ ` _.~~- _
<br />in. fo
<br />ft.
<br />
<br /> •
<br />PROPERTY OWNER'S NAME/COMPANY NAME in. to ft. Ibs tft.
<br />~ --- - --- in. to__ft.
<br /> ~~ ,~ 1 ~1/ ~ ~-~ j~r~! .r~,t.,_,.t
<br />S in. to ft. Ibs.rft. -- - in.lo ft.
<br /> OPEN HOLE
<br /> Location address indicated ab~ve.
<br />malling addr it different than well A
<br />Property owner's
<br />' SCREEN ~. __
<br />~
<br /> ~' r i 1 n"L,1 r .F_
<br />.( ~" r'`~./
<br />y ~
<br />(
<br />• (~
<br />~
<br />"~
<br />- .> (~ /~
<br />Make ~ L' fl r"l
<br />Fr
<br />f
<br /> .
<br />,,,
<br />,
<br />-
<br />-
<br />Type _-- ! ~ G om
<br />t. To_ ft.
<br />Diam. :'
<br /> j
<br />~- ~ ~
<br />~
<br />f
<br />i
<br />,~
<br />"
<br />}
<br />-
<br />/:•- ~
<br />~ SIoVGauze ~ ~~
<br />Length
<br />1 D --
<br /> ~
<br />L-C1L
<br />.
<br />-~
<br />.-
<br />/ r
<br />~
<br />j
<br />~ J
<br />;~
<br />.
<br />J ~ _
<br />_
<br />t
<br />i ~
<br /> Set between _
<br />"t
<br />ft. and_~ ft. FITTINGS ~ / [ [ S h J U s !l"f'
<br /> STATIC WATER LEVEL
<br />~ ( Measured from
<br /> _ "'" ~ _tt. ' elow ^ Above land surface Date measured
<br /> WELL OLNN~R'S NAMEJCOMPANY NAME PUMPING LEVEL (bel land surface)
<br /> ^! ~'° ft. after hrs. pumping_____^_g,p.rn.
<br />WeIlPooring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION
<br /> [ ] Pitless/adapter manufacturer Model__-_
<br /> Casing Protection ~ _ L7 I'~! 12 in. above grade
<br />~
<br />`
<br />[
<br /> At-grade (Environmental Well and Boring NLYj
<br />}
<br /> GROUTING INFORMATION
<br /> Well grouted Yes I_I No
<br /> Grout materials eat cement [] Bentonite ^ Concrete ^ Other
<br /> From _ To_ tt. _
<br />^ Yds. ~ ags
<br />-
<br />~~--
<br /> _
<br />~
<br />~
<br />~
<br />~_
<br />GEOLOGICAL MATERIALS COLOR HARDNESS OF
<br />MATERIAL FROM TO From
<br />To
<br />tt.
<br />- -__ ^ Yds. Bags
<br /> From To_ R __ ^ Yds. [] Bags
<br />~~~ _ +
<br />~(
<br />
<br />r
<br />
<br />U
<br />~ \
<br />~ NEAREST KNOWN SOURCE OF CONTAMINATION
<br /> ~
<br />~ ~I
<br />r
<br /> -~!
<br />feet _~direction
<br />type
<br /> __
<br /> " Well disinfected upon completion? ^ Yes ^ No
<br /> PUMP
<br /> Not installed Date installed __
<br /> anufacturer's name
<br /> Model Number_ _ _ HP,_ Volts ___-,.
<br />
<br /> L ength of drop pipe _ tt. Capacity __ g,p,m,
<br /> T ype: [] Submersible ^ L.S. Turbine ^ Reciprocating ^ Jet ^
<br /> A BANDONED WELLS
<br />
<br /> d oes property have any not in use and not sealed well(s)? ^ Yes o
<br /> V ARIANCE
<br />
<br /> Was a variance granted from the MDH for this well? ^ Yes (~ o TN;t__
<br /> WELL CONTRACTOR CERTIFICATION
<br /> T his well was drilled under my supervision and in accordance with Minnesota Rules, Chapter 4725.
<br /> T he information contained in this report is [rue to the best of my knowledge.
<br />Use a seco nd sheet, rf needed.
<br />REMARKS, ELEVATIOPJ, SOURCE OF DATA, etc.
<br />
<br />/ , ,y--,--,~` ~J~- ~_~
<br />LZ€nSee~Bwskre5s~-te
<br />m r ' ' ' r L, t r~.
<br />'~
<br />f
<br />-NO
<br />r ~
<br />~ .
<br />a
<br />e
<br />e .
<br />.
<br />
<br /> rtified Representative Signature Certified Rep. No. Date
<br />Ii:~PORTANT -FILE !KITH PROPERTY PAPERS
<br />^
<br />~ ~ ~ ~ _-~-r-_ -/~ ..~' _ ~
<br />~ ~
<br />~ ---
<br />bVF~.L ONiN R C
<br />vFY NEmc~ot9nllar
<br />~-
<br />IC 140-0020 HE~01 Z06-.C (Rev. 6i06)
<br />
|