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HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BOR/NI�G NO. ELL CountyName WELL AND BORING RECORD �, � 3� � g Hennepin Minnesota Statutes,Chapter 1037 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 11$N 23W 29 ,, �,, SF 162 tt. Auguat 1, 20t?7 � GPS DRILLING METHOD - ; LOCATION: Latitude degrees minutes seconds �i LongiWde degrees minutes seconds ❑Cable Tool ❑Driven ❑Dug ❑Auger �,I Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � 3560 6th Ave A, I+OT1g L8� DRILLWG FLUID WELL HYDROFRACTURED? ❑Yes �,No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. �8t�r From ft.To ft. Showing property lines, N roads,b�di���d#ection. USE �Domestic ��Monitoring ❑Heating/Cooling �.; � � � � �...�,,•� – - �; __:____;___ ___L____:__ �]Noncommunity PWS I ]Environ.Bore Hole ❑Industry/Commercial �`� �� ❑Community PWS �_�Irrigation ❑Remedial I I I I •; ;� . _ .: --'--- --+-----`-----;– ��'�`� �l Elevator �_J Dewatering ❑ �1 W , , � � E � CASING MATERIAL � , , ; ; T 1 Drive Shoe? ❑Yes �]No HOLE DIAM. --�--- --�----�----.– � �� , , , , 'h Mile elded ❑Steel ❑Threaded �]W , , , . � �]Plastic � �211� --;-- --T-----�-- --�- CASING � g � Diameter Weight Specifications ��Miie—� � � �� � in.to 1 S 7 ft, Ibs./ft. �. in.lo�ratl_ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to n. ibs.in. 6; in.toiv2 ft. T@X SIld �OI111$ Ostvig in.to ft. Ibs./ft. _ in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE 3560 6th Ave H Make .T8�C0 From ft. To ft. � uaa.a� � S5356 Type ___�� __Diam. * g SIoUGauze 1� Length t S Set between �S7__ft.and 162 ft. FITTINGS A j3$��Qr STATIC WATER LEVEL r�� Measured from o �3 ft.j[;Below ❑Above land surface Date measured_q 1 O7�'� WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) T�7C �1� �flfl� �s�ig ft.after hrs.pumping SQ g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION H �Pitless/adapter manufacturer �a88 Model � ❑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.1Q—To�.�ft _�__ ❑Yds. �]Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_._To ft. _ �I Yds. ❑Bags MATERIAL From To fl. [1 Yds. r;�Bags NEAREST KNOWN SOURCE OF CONTAMINATIONdvel SOt fLO� S�V�Z C�y yell� � J� ___feet __direction . type Well disinfected upon completion? �Yes ❑No �� gray 3� 90 PUMP (� n [;Not installed Date installed G � ' � �� • ��� � 8�� =�d 9� 124 Manufacturer's name � � 1 y t �.��'t- ��C.�� ! . + j 3 Model Number HP 1 Volts elay gray 120 140 4 �a Length of drop pipe `��.' 1 ft. Capaciry ` � g.p.m g� gray iy� 262 Type:�Submersible ��LS.Turbine ❑Reciprocating ❑Jet ❑ 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 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,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Stevens Dzilling S Bnv. Svc, Inc. 2255 Licensee Business Name � Lic.or Reg.No. !...� . , ��'_ ,���--- SbbS� 8/8/07 Certified Representative Signatu Certified Rep.No. Date LOCALCOPY 7 �3539 ��Y'�{'� ���r ��U Name of Driller IC 140-0020 HE-01205-10(Rev.6/O6) '�, 1' MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 2 5 7�9 8 ;: WELL OR BORING LOCATION Sealing No. H � County Name WELL AND BORING SEALiNG RECORD Minnesota Unique Well No. � Minnesota Statutes,Chapter 1031 or W-series No. � Henaspia (Leave blank if no�knownJ Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Orono 118N 23ii 29 '� '� SE'° August 16, 20Q7 GPS Latitude degrees minutes seconds Depth Before Sealing_ �"O� __ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds A�UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ��Single Aquifer ❑Multiaquifer 3560 6th Av� N� �11g LQs� WELUBORING �I Measured �Estimated Date Measured_8 I6 07 �Water-Supply Well �]Monit.Well Show exact location of well or boring Sketch map of well or boring . in section grid with"X" location,showing property U Env.Bore Hole ❑Other_ _ �S ft. �below ❑above land surface �# N lines,roads,and buildings. CASING TYPE(S) ' --'-- --'----`-- --'— - �f Steel ❑Plastic ❑Tile ❑Other _ � --''-' "�-'- "'`-- --'`'- WELLHEAD COMPLETION �� � W ; � � ; ET - - �� � � � � Outside: �]Well House ,_;At Grade Inside: [�Basement Offset � —�--- ---�—--�-- ---.-- ; ; ; ; ; Miie . Pitless AdaptedUnit ❑Buried ❑Well Pit �M �� --.--- --r----�-- ---:- 1 - ❑Buried S �Well Pit ❑Other i �—�nniie� ❑Other , � PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) T�X and Donna �StY� Diameter Depth Set in oversize hole? Annular space initially grouted? Properry owner's mailing address if different than weli location address indicated above � in.from O to � ft. Yes � ❑No ❑Yes ❑No �Unknown 3560 6th Ave I� Loag Lake. rIII 55356 � in.from 5 to 101 ft. �Yes ❑No ❑Yes ❑No �]Unknown in.from to ft. � �Yes '.�,��No ��.��Yes �, �No r;Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE Tea aad Doana Ostvi ■(� S Well owner's mailinq address it different than prooerty owrer's address indicated above SCreen from jM� _tp 10+_ .ft. Open Hole from _ to ft. OBSTRUCTIONS ❑Rods/Drop Pipe U Check Valve(s) ❑Debris ', '.Fiil �No Obstruction Type of Obstructions(Describe)_ _ _ _ GEOLOGtCAL MATERIAL COLOR HARDNESS OR FHOM TO Obstructions removed? ❑Yes �No Describe FORMATION PUMP ` ..; If not known,indicate estimated formation log trom nearby well or boring. �� { , , . TYPe �1 I :_. �C_�.__ ` ��Removed ❑Not Present ❑Other _ . METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �;No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe �J Casing Perforation/Removal in.from to _ft ❑Perforated ❑Removed in.from _to tt. ❑Perforated ❑Removed Type of Perforator_ ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) 1 1 a Grouting Materiala�at C�t_ from � to 1fl5_ ft. yards2Z bags from_ ro ft. yards bags _ ___ _ from to _ ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES 1N SEALING Other unsealed and unused well or boring on properry? �j Yes �j No How many? UCENSED 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. ' Stevens Dri113ng � Environ�ental Svc Inc._____Z_�,�,� ___ ___ `- Contractor Business Name License or Registration No. ' 86b54 �17107_ . -- - - - _---- — - Certified Representative Signature Certified Rep.No. Date � 'S H 2 5 7 a 9 8 Patrick 3ohnson ; ' LOCAL COPY — — — __ __ __ _ —_ _— _ _.__ Name of Person Sealing Well or Boring j� HE-01434-09 IC#140-0423 s/osa j j� . . .. . . . .