HomeMy WebLinkAboutwell info MINNESOTA UNIQUE WEL"L
�L�30!�I�LOCATION MINNESOTA DEPARTMENT OF HEA�TH AND BOR/NG NO.
�o„�,y N�,�� WELL AND BORING RECORD � � �� � �
Minnesota StaWtes,Chapter 1037 �
Township Name Township No. Range No. Section No. Fraction WELVBORING DEPTH(completed) DATE WORK COMPLETED
�� �� �� fl.
�=. GPS DRILLING METHOD
�- LOCATION: Latitude degrees minutes seconds
; ❑Cable Tool
Longitude degrees minutes seconds ❑Driven ❑Dug
❑Auger �Rotary ❑Jetted
House Number,Street Name,City,and Zip Code of Well Location or Fire Number �
DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No �
Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. ��t�te From ft.To ft.
Showing property lines,
N roads,buildings,and direction. USE �Domestic �_Monitoring ❑Heating/Cooling
; � � � � �.
>. __J____1__ ___�____L__ "� ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial
� ❑Community PWS �Irrigation ❑Remedial
--1------;-- ---F-----t-- �]Elevator ❑Dewatering ❑ '
1 �' , , , ; E T �ti CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM.
' --+-- --�-- --F—---<-- - �
I �: [j Steel ;]Threaded ❑Welded
` ' � ' � Mile StIC
i�
, , � Pla ❑
; --�--- --�-----�----�- t ,,,.
� I ; ' ' � CASING �S
;' S � Diameter Weight Specifications
[�N e �n
�—1 Mile� '* in.to 1a�_ft. �i9 Ibs./ft. �� � in.to .7V ft.
e � Q
a PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. �in.to�j�ft.
in.to ft. Ibs./ft. in.to ft.
Property owner's mailing address if difterent than well location address indicated above.
SCREEN OPEN HOLE
- AL �+f�_� n�7 Make � ��,t.,. * From ft. To ft.
21P�f .71i�1� iU,i Type $iPil[1Z�.'�s Sti Diam.
�trj� E'II7 SS�� Sbt/Gauze�_rn� Length �� ��l� �}���
z Set between ft.and ft. FITTINGS �
STATIC WATER LEVEL
� Measured from
ft. elow ;]Above land surface Date measured � �
WELL OWNER'S NAMEJCOMPANY NAME PUMPING LEVEL(below land surface)
' !v� ft.after ��� hrs.pumping 25 g.p.m.
�' Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ���
-1� - � F
��Pitless/adaptermanufacturer iJ.�'I -�-��`��fl"�'�Idd�f
❑Casing Protection �712 in.above grade
❑At-grade(Environmental Well and Boring ONLY) ��`
GROUTING INFORMAT ON
Well grouted �Yes ❑No
Grout materials J Neat cement�Bentonite ❑Concrete ❑Other
From_�To�' ._ft. � i]Yds. �Bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From '�__To�.g'�_ft. �_�'r�. ❑Bags
MATERIAL From To ft. ❑Yds. ❑Bags
1.� NEAREST KNOWN SOURCE OF CONTAMINATION
CJ.iTy Il� �Lt � l� �'-" :J feet �.,ti _,—_direction ^d� ��.-:�-:^"-s�-..rrype
Well disinfected upon completion? ' Yes ❑No . ;..,,,;,,,,,,, t � �..,j,�
clay ray - soft I6 b3 PUMP /
c L ❑Not installed Date installed ! � � � �
$��t �� �i� G� �� Manufacturer'sname ��-.�—`+�--'`�✓"�'ti���`"�'+"�--
Model Number HP /�Volts
ciay ropn sofr iS0 180 �
Length of drop pipe �J v ft. Capacity g.p.m.
3CiilCl � �ft 4$A 1 A5 Type: Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑
1 V 17
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑Yes No
VARIANCE
Was a variance granted from the MDH for this well? ❑Yes No TN#
WELL CONTRACTOR CERTIFICATION
s
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Use a second sheet,il needed.
REMARKS,E�EVATION,SOURCE OF DATA,etc. �1 ,S'toc�ola Well Drillir.� Co• ��• ZU7�
Licensee Business Nam � Lic.or Reg.No. �
' ... ! h .�1r"✓� ? -
C resentative Signat re Certified Rep.No. Date F
�
' � �O�` � Name ot Driller � �re
, LOCALCOPY
IC 140-0020 HE-01205-10(Rev.6/O6)
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T'w�vv C ' u�c�.t� C ' ' , I v��,c�
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617 13th Ave So � Hopkin:�, Minnesota 55343 � (612) 935 - 3556
06/OS/2007
Srodola We!! Drilling
3841 NorCh Main
St. Bonifacius MN 55375
938-21 1 1
REPOR I'OF WATER ANALYSIS
�
Lab#: 2046N
Our Laboratory reports these analyticat results, determined on a sample Caken
by CUENT on O6/04/2007 from the foll��wing /ocaiion:
Wi�liam Titler
4;!09 north Shore Dr
Orono,Mn
IN'PII 750629
Coliform Bacteria Absent
Nirrates Nitrogen <1,'0 mg/!
The resulis o f these tests indicate tl�at this well is producing water rhat meets the
standards for f.H.A., V.A., ar,convenc.�c�r�al bans. This reporr is an analysis fvr
coliform and nirrate only and does �ar i►�clude ai�alysis of Lead and other
coniaminants. (Unless as specified hy client).
Twin Cit Water Clinic, lnc.
Bil1 V n r dale
L ob f'crtification i!027-OSi-i 19