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Home My WebLink Aboutwell info ... �...,. ,,-. y -q4 .. � ,p� }�._� r ., .�. ..' � . . . , :" �• q .,:.. .�,,. �- . . , ,.. ,:.�„ � ..`r�a, � .. .. . :..� '. . .. � � ' MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring 1366 4 J I WE��oR BOF�N��o�AT�oN ___ WELL AND BORING SEALING RECORD Sealing No H Counry Name H�411@ 112 Minnesota Statutes,Cha ter 1031 Minnesota Unique No. � j� p or W-series No. (Leave blank if not known) Township Name Township No. Range No. Section No. Fraction�sm.-s Ig.) Oate Sealed Date Welt or Boring Construded r�no �17 23 2 ,, ,, �i/17/98 Numerical Street Address or Fire Number and City of Well or Boring Location ^7 ��V� .S�l�t 't'�I Z�� r 1 V'4'� Depih Betore Sealing 1 /� ft. Original Depth 1�l ri. � Show exact location of well or boring Sketch map of well or bonng AOUIFER(S) STATIC WATER LEVEL in section grid with"X". �J`� location, showing property �Single Aquiter ❑ Multiaquifer lines,roads,and buildings. N WELUBORING �Measured ❑ Estimated � � � � [$Waler Supply Well ❑Monit.Well II I , ��S ' ❑ Env.Bore Hole ❑Other _ 44 tt. �elow ❑ above land surface W --�- -i-- -i-- --i— E j . CASING TYPE(S) � � � � .� ' � � -�-- -�-- -�-- --�-- � ; [�Steel ❑ Plastic ❑Tile �Other � � � � u mde � --�- -�— �-- --1 � ' -r .x`�.. �t �� CASING - -. r .i...,�" <.�.'_`:._. �-��-- �� Diameter Depth Set in oversize hole? Annualar space initially grouted? S ��J"� r � � � ��7 V Yes ,Y No Yes No Unknown �t mae—�e _ _. � ` � �; � in.from to fl. ❑ L7' ❑ ❑ � I PROPERTY OWNER'S NAME in.from to fl. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown i�ar� H.o�rar� Properry owner's malling atldress if diNerent than well location address indicated above. in.from to k. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown �t30 S. �'1 uth ltaad Mi�netdnKa, �� 55:iU5 SCREEWOPENHOLE � Screen from+5L5L to�i� ft. Open Hole from to tt. OBSTRUCTIONS WELL OWNER'S NAME [$Rods/Drop Pipe ❑ Check Valve(s) ❑Debris ❑ Fill ❑ No Obstruction Well owner's mailing address i�di8erent than properry owner's adtlress indicated above. Type ot ObSlruCtions(DesCribe) � �0• .�1�e dn�� i r e Obstructions removed? � Yes ❑ No Describe PUMP Type �uiom�rsible GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO '�Removed ❑ Not Present ❑ Other FORMATION It not known.indicate estimated formation log from nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: C�r 1��i � ,,�l �No Annular Space Exits ❑ Annular space grouted with tremie pipe ❑ Casing PerforatioNRemoval in.from �o h. ❑ PeAorated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of peAorator ❑ Omer GROUTING MATERIAL(S) Grouting Material ��'�t j'�'$� from 1�1 to V k. yards 1� ba s 9 from to tt. yards bags from to ft. yards bags from to-- tt. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes �No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. HES Weil yrillin� 1'll7b ,, ' ' :��_ f�'��0. ontractor usiness Namg License or Registr on /t Authorized Representative Signature Date J d;n�� L�a LOCALCOPY H 13 6 fi 4 9 Name ol Person Sealing Well or Boring HE-01434-03 2/97 R �Li+)"�F l35y`..1� . f..� �� .c..�. -....:. :. .. ..::......s. ..... , ...�. t . . � . �` .. ., WELL OR BOFING LOCATION MINNESOTA DEPARTMENT OF HFALTH Minnesota Weil and Boriny ; 136�5 0 � ; County Name WELL AND BORING SEALING RECORD Sea"�g"°. i H _ _.. Minnesota Unique No. � — � ji�.a��.a�l� Minnesota Statutes,Chapter 1031 or W-series No. ILeave blank if not known) Township Name Townshlp No. Range No. Seclion No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Consiructed Oron� �17 23 2 , ; , 6/t7/��3 Numerical Street Adtlress or Fire Number and City of Well o�Bonng Location 1.30V ShuteYine L�r�.�@ DepthBetoreSealing �� ft. OriginalDepth f.� h. Show exact locatwn of K•ell or boring -\ Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL in section grid with"X". A /- 1 location, showing property �Single Ayuifer ❑ Multiaquifer !v ! lines,roads,and buildings. N WELUBORING �] Measured ❑ EsGmated � � � � „ n ^ �]Water Supply Well ❑Monit.Wetl -�- -�-- --i-- --� ci,` t � V jU �. ' ,. ❑ Ern.Bore Hole ❑Other _ ��l tt. ❑below ❑ above land surface � -�- -=-- --=-- ----- x � !� yy E i' CASING TYPE(S) - � � � � � � � � � � � —�- —�- --i-- --�-- � i. $�Steel ❑ Plastic ❑Tile ❑ Other %md9 „ n. .'� . . . � • �, ,, . . � ` �; � ' ' ' ' ��' .' .. � CASING —�- -�-- -�-- --�-- Diameter Depth Set in oversize hole? Annualar space initially grouted? S '��J"� .;{ i,: 'r, �. ;-._i ! - i l � �3 �r mi�e—�e in.6om to ft. ❑ Yes �No ❑ Yes ❑ No ❑ Unknown I PROPERTV O ER'S NAM in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown r;on �oa�ar� Property owner's mailing address if diHerent ihan well location address indicated above. in.from to ft. ❑ Ves ❑No ❑ Yes ❑ No ❑ Unknown LL�O S• PI�tLil�uti� Ri,�CZA SCREEWOPENHOLE �1 rltli3t'iOL1Kd� � �J�J 3 a� Screen from l'} to l? ft. Open Hole from ro ft. OBSTRUCTIONS WELL OWNER'S NAME ,$] Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill�]No Obstruction Well owner's mailing address if different than propeAy owner's atldress indicated above. Type of Obstructions(Describe) Obstructions removed? ❑Yes ❑ No Describe PUMP Type �EOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed Q Not Present ❑ Other FORMATION If not known,indicate estimated tormation log from neaiby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: a►r i f t � �� No Annular Space Exits ❑ Annular space grouted with tremie pipe ❑ Casing Perforetion/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ PeAorated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) Grouting Matenal��r�1�� trom �7 to v ft. yards 1 bags . from to ft. yards bags from to ft. yards bags from to_ k. yards bags REMAHKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes �No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this repoR is true to the best of my knowledge. itEs i��11 t�rilli�� 2727b Contracror Business Name / License or Regishation lvo. � / ,.. _. � � - : r ! r- ' � f�,�:. " . 1�- / J /�' _ � '.� , Authorized Representafive Signature ate - � Jam�� i,ea LOCALCOPY H 13 6 6 5 0 Name ol Person Sealing Well or Bonng HE•01434-03 2/97 R � F��:�� MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. oEntyNO eATION ` ;! f� � ?""�yELL AND BORING RECORD � � • Minnesota Statutes Chapter1031 5 9 1 5 4 5 't'I..Slrif..}�11'1 �_ .�;_,,_,: Township Name Township No. Range . Section No. Fraction WELL DEPTH(completed) Date Work Completed n ,, .i. �. House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOO ❑ Cable Tool ❑ Driven ❑ Dug f7 Auger � Rotary ❑ Jetted Show exact location of well in section grid with"X". - Sketch map of well location. i�J _ _______ Showing property 6nes, roads and buildings. DRILLING FLUID N ' i i i i_ � �� :�5 _1_ '-' _i_ _i �� ' . USE ❑ Monitoring ❑ Heating/Cooling � � i i Domestic _�_ _�_ _�_ _�_ � � � � ❑ Community PWS ❑ Industry/Commercial i , -..,�� i� ,•� ❑ Irrigation ❑ Noncommunity PWS ❑ Remedial ; y,� ' I E .,..l,� ❑ Test Well ❑ Dewatering ❑ -r -�- -r- -r T i i i i ,�'M e � CASING Drive Shoe? X] Yes ❑ No HOLE DIAM. _i i L � I � Steel ❑ Threaded ❑ Welded i- - i- i i � - s �! � ' � i - { � r_ ;-.._-�-__� 1 ❑ Plastic ❑ — - ! �1 Mile-� -�.��...�� —"".'."""-. � � - �`" CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME 4 in.to 1 13_R _ _ IbsJft. t'i in.to�j�ft. in.to _ft. _ Ibs./fl. � in.toy__J,__j_ft. . Property owner's mailing address if diflerent than well locafion address indlcated above. in.to _tt. Ibslft. " __1_�� i i ry� �23� .�!• plymouth �d SCFiEEN OPENHOLE Make trom ft.to ft. �iinnetonka, MN 55305 Type SL"a1�12a�,S Diam l SIoVGauze �� _ _Length � � - � Set between 117 R.and 1 x tj ft. FITT�,r��' j��;� STATIC WATER LEVEL WELL OWNER'S NAME h��J tt�Q7 below ❑ above land surface Date measured PUMPING LEVEL(below land surface) � Well owner's mailing address if different ihan property owner's address indicated above. lj� ft. afler � hrs.pumping ,y�� g.p.m. WELL HEAD COMPLETION �7 Pitlessadaptermanutacturer W't]1teWr"]1:F±iL ModelS—�� C7 Casing Protection_ CJ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) 4 GROUTING INFORMATION I � Well groutetl? � Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout tv�ateria� C Neat cemern ❑ Bentonite ❑ Concrete ❑ High So�ids eentonite MATERIAL from�g_�o__�_tt. � ❑ yds.�] bags , from to ft. ❑ yds. ❑ bags Sand Clcl $Zoidll Med 0 21 from to n. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION Cla � Gravel Blue Mi M�d 'll 3 ---�� feet �}ja�� _directiorLj��_j�t�pe � Well disinfected upon completion?h'CI Yes CJ No Cla Hlue Med 30 36 PUMP � ❑ Not installed Date mstalled ��7;�f� Manufacturer's name ��+.�;_��,-4i, � � -^ ' Sz1riL� � Gravel MfX SOft �6 lUS Modelnumber HP �. vous l:�U Length of drop pipe C��t ft. Capaciry l�it g.p.m. sr�ji�i �,'la� B,1(je SQgt ,�� 11� Pressyure� TankCapacity_ �A�tQ Type�L7 Submersible ❑ LS.Turbine ❑ Reciprocaling ❑ Jet � _ �} ��a ABANDONED WELLS �y f ' Does property have any not in use and not sealed well(s)? ❑ Yes •''C] No VARIANCE A Was a variance granted from the MDH for this well? � Yes Xp No -. WELL CONTRACTOR CERTIFICATION � Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. __ REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to the best of my knowledge. 1�E5 Well Dxilling t7t" Licensee Business Name Lic.or Reg.No. Authorized Representative Signature Date r2onert E Stodo' Name ol Driller Date LOCAL COPY 5 915 4 5 HE-0,zo�,Re�.,,�5, �