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Home My WebLink AboutWell info MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING RECORD � � �5 Q 3 Iiennepin Minnesota Statutes,Chapter 103I Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED s Orono 117N 23W 14 ,� ,� S$� 152 h Feb. 28, 2007 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds ]Cable Tool [j Driven ❑Dug -- J�Auger �Rotary ❑Jetted - House Number,S[reet Name,City,and Zip Code of Well Location or Fire Number �� 1850 Shoreliae Dr, WByZaCB DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. �entonite From ft.To ft. Showing properry lines, N roads,buildings,and direction. USE s . �Domestic ❑Monitoring ❑Heating/Cooling r, __L____�__ __L___L_ �� _-�.._.-� ❑Noncommunity PWS ❑Environ.Bore Hole []Industry/Commercial � ❑Communiry PWS ❑Irrigation :�l Remedial � --'--------- --;-----'- ❑Elevator ❑Dewatering ❑ W � � � E ...--• ---�-�.,.-.-,�.�.....�..a,,,,,,,,�....,.s,,,,�.,,,.,..,�.,..,...V.... „ -� .. ; , T _.__ _�,_„�,n,_,,,�,,,.,,.,e,,,,,,,,,,,._,.ro�__..,,_ CASWG MATERIAL Drive Shoe? ��Yes �No HOLE DIAM. --�--- ------- � � � � � � I ❑Steel ❑Threa d ❑Welded �� , , 'fe Mile � ; � � i, Plastic � e� � --�-----�-----�-- --�-- ^. 1 u ; ; ' ' � CASING g � �-'�.�, ;,,� Diameter Weight Specifications ,L-� 7 A�f �1 Mile� l�e'� � t.�-,!�,''_Q � in.to ��" ft. IbS./ft. `� Il1.t0�O ft. PROPERTY OWNER'S NAME/COMPANY NAME ! in.to ft. Ibs./tt. 6• in.to 1 S� Tro.y Broi t ziaan in.to_ ft. Ibs./ft. in.to n. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE 1860 Shoreline � Make apCQ From ft. To ft. �ByZStB� MN 55391 Type Diam. Slot/Gauze t Length__ Set behveen 147 R.and iSZ ft. FITTINGS k packer STATIC WATER LEVEL ground x 2 Measured from�'J�j'F�� q ft.�Below �,�Above land surface Date measured `�� -"f� _ WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) Tray Brc►itz�an ft.after hrs.pumping �� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION „ y�Pitless/adapter manufacturer �g�s Model 4 ❑Casing Protection ❑12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted �Yes ❑No Grout materials ❑Neat cement�'Bentonite ❑Concrete ❑Other From 8 To �� ft. � ❑Yds. L�Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. ❑Yds. ❑Bags - MATERIAL i From To ft. ❑Yds [�Bags CZfl� �/@llO�i Q 13 NEAREST KNOWN SOURCE OF CONTAMINATION�VGr r�i seWer ___ feet _ direction ____ type 8811d gI'&y 13 32 Well disinfected upon completion? �Yes ❑No PUMP C18q grH51' � 3z 11� ❑Not installed Date installed � -"� ! �� t.�`, , 1 f� Manufac[urer's name �� - sand bTOiiFI ;i� I21 Model Number HP Volts_ �,(/ � � Length of drop pipe s.i�✓ ft. Capaciry g.p.m. C�.BY �t 88t1(� brawu 1�1 1•FS Type:[1�Q Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS �and & gravel $T8� 1�5 1 rJ 2 Does properry 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 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,ELEVATION,SOURCE OF DATA,etc. Stevens Dril2ing � Enviroriaental Svc �2?.55 Licensee Business Name Lic.or Reg.No. : .. ,.,. ,,� t. ` _ -_�-x6�s.�. � . ��-�/�.� Certified Representative Signature Certified Rep.No.� Date Rar�dq Johnson LOCAL COPY 7 ��5 0 3 -- ' Name ot Driller IC 140-0020 HE-01205-10(Rev.6/O6) �/ 1 WELL oR BORING LOCanON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„' f�A� County Name WELL AND BORING SEALING RECORD MinnlesotaoUnique Well No. `3 Hennspin Minnesota Statutes,Chapter 1031 1�W�� Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Construc[ed Orano 11?N 23kt 10 ,. .,. S� =:—L�}--C ;.r GPS Latitude degrees minutes seco�ds , �. LOCATION: Depth Before Sealing V '� ft. Onginal Depth �``�� ft. Longitude degrees minutes seconds ppUIPER(S) STATiC WATER LEVEL i� Numerical Sheet Address or Fire Number and Ciry of Well or Boring Location Single Aqui(er ❑MultiaquNer - - 1860 Shoreline Dr, Wayzatn WELUBORING �Measured ❑e��rea �Water Supply Well ❑Monit.Well Show exact location of well or boring Sketch map ot well or bonng .::k ;-. in section gnd with"X" location,showing property ❑Env.Bore Hole ❑Other f�^ ft. bebw ❑above land surface N � lines,roads,and buildings. CASING TYPE(S) �% - - - - - -- - - �1 .u..''� I � � �„Steel ❑Plastic ❑Tile ❑Other W --� -- - -- --i-- E � WELLHEAD COMPLETION � � � � � � - Outside: ❑Well House Inside: ❑Basement Offset � --r- --r- -�-- -- -- . . �^�'b � ❑Pitless Adapter/Unit ❑Well Pit - -;- -i-- -i-- --i-- I 1 � �Well Pit ❑Buried ' S . _ '�. .._. .._..._._.._.�..__.. :. �r rrwl�� . � -� .—.r..•—,�``,-=a—....- ..'.._'..." ❑Buried PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Trc�� YDlt2'1l1cdT1 Diameter Depth Setinoversizehole? Mnularspaceinitlallygrouted? Property owner's mailing address if diHerent than well location address indirated above ,� �. in.ffOm �--' to '"—' ft. ❑Yes f�7 No ❑Yes ❑No �Unknown t8�i0 Shc►reline Bz •r� Tdapaata, Mtd 55391 in.from to n. ❑res ❑No ❑ves ❑n,o ❑Unknown in.from to ft. ❑Yes ❑No ❑ves ❑No ❑uMcnown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE T�'O" BtOit2laan - Well owner's mailing address if differeM than property owner s address indicated above Screen from ��' to '"'`� ft. Open Hole from t0 ft. OBSTRUCTIONS �( Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ,Yes ❑ NO Describe FORMATION If not known,indicate estimated formation log from nearby well or bonng PUMP Type _ :�-, �:� �Removed ❑ Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforadon/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �� ; i:a_� Grouting Material � from to (t. yards � bags from to ft. yards bags from ro ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING pther 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 infortnation contained in this report is true to the best of my knowledge. S�e�se��: ')rzl.li.ng �4 Er��srirc�ixn�r,��l Svc 8665� Contractor Business Name License or Registrafion No. �/��,'�` �(.�, . - .. . - r ��. r Authonzed Representative Signature Date LOCAL COPY H �35246 � :�,�-�.�� r� �_, ,.; , � ��.,��.) Name of Person Seal�ng Well or Bo