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Home My WebLink Aboutwell info MINNESOTA DEPARTMENT OF HEALTH Mmnesota Well and Bonng `— � , WE��oRBop�N��AT�oN WELL AND BORING SEALING RECORD SealingNo �H 141701 Counry Name — Mmnesola Urnque No. Mmnesota Statutes,Chapte�1031 or W-senes fvo. 21112e #.22 ILeave Wank d rw�known� Township Name Townshlp No. Range No Section No. Fractlon�sm.-i Ig.) Date Sealed Date Well a Bonng CaWn,ctea ,�To 118 21 30 "11�`��}. �1 Z 9/99 2�A Numencal Street Adtlress or Fire Number and Ciry ol Well or Bonng Location 85 Stubbs Ba Ro�d, La�.e *Qt 55356 Depth Before Seahng 13� fl Origlnal Dep�h h Show exad location of well or boring Sketch map of well or bonng ApUIFER�S) STATIC WATER LEVEL in sectron gnd wrth'X'. - bcation, showing p�operty Single Aywfer ❑ MulUaqwfer Gnes,roads,and buildmgs. N WELL/BORING �Measured ❑ Est�mated Water Supply Well ❑Monit Well ❑ Env.Bore Hole ❑Other _ Q�} ry. �pelpw ❑appre land wAace W --'"- - -- - -- --'-- E CASING TYPE(S) -i-- ---- -i-- --�-- � Steel � Plastic �Tile �Other F mile --`- -�-- -�-- --i-- � CASING Diameter DepM Set m overs1ze hole? �yy�„rpary ywled7 �t�—�►e `� in.from � to Z 3� ft. ❑Yes �d-1 No ❑Yes ❑No �]UNuwwn I 1` �` PROPERTV OWNER'S NAME in.irom to fl. ❑Yes ❑No ❑res ❑No ❑UNvn�^ P Pp�qrb ownefs maihrg address if tllflerent than well iocation address indicated above. in.from to ft. ❑ Yes ❑� ❑r� ❑� ❑�Q� Y O.� k85 Stubbs 8831 �c�.F2 SCREEWOPEN HOLE lLBng L�ke, MPT 55356 Screenirom 1�� to z3� n o��f,aer.� b R. OBSTRUC710NS WELL OWNER'S NAME Rods/Dro Pi �No ObunxUon ❑ p pe ❑Chedc VaNe(s) ❑Debris ❑Fill Well ownefs meiNrg address if ditterent than property owner s address indicated above. Type of Obstructions(Describe) Obstructions removed? ❑Yes ❑No Describe PUMP Type (iEOLO(i1CAL AIATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Otlier fORMATION H rat kravm,kidicate eatimated tormatbn log trom nearby well or bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASp1GS,OR CASN('A!b BORE HOLE: 'Q,,L�, No Annular Space Exits LJ Annular space grouted with tremie qpe ❑ Casing PeRoratioNRertaval in.from to 1t. � PaAara�ed ❑ Fian�wad in.from to R. ❑ PaAoralsd ❑ Ranwred Type of peAwata ❑ Other GROUTING MATERIAL(S) Grouting Material ��'t fiw�t, r,a,,, 4 � 130 � � 21 � rrom ro R yards tnps hom 10 R pbs bqs from to R Ya�ds ��ps RENARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boreg m property? ❑Yes No Fio�r marq/? UCENSEO OH REGISTERED CONTAACTOR CERTIFICATION This well or boring was sealed in acoordence with Minnesota RWes.Chaplx 4725. The iromqYon caMrrd i�hs�aport's true to the best of my knowbdpe. ��'�� Sreve*�s T►ril_?i;�� & E:av. Servlces 866�4 �� 57�J Conhador Business Name (i�rw or Repsla�on Ria Q� -- 2l1199 i:.,;' - " �.i"'.�i i;�: Autlwrized RepresenfatiNe S1gneNie Orb Richard Steve:a� LOCAL COPY H ! �� Neme ol Person SealinD WeN or Bonrg 1 HE-01�3/-03 2�J7 R WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD 612 �0 6 ��r�'��.�" Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed �rc�nt I1� ^� 3a �,,, ,{�',� {�"t.t�t�. If�? �� 12/7/9� House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug „ 4%rs5 Stut3bF h�v Ro�d, I.n-�q I��ke 5S 55 ❑ Auger Ltl(Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ _ � Showing property lines, ... - roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO N �.�..�.�..�'_"'.^-•'y `�_��.p� ,� WK`�� FROM ft.to ft. i i i i - -i -�- -�- -i- � }.!.r '= ,�_.�--�--•'"� USE ❑ Monitoring ❑ Heating/Cooling i i i i L\, f3�pomestic _i_ _�_ _�_ _i_ �--"`� � ❑ Community PWS ❑ Industry/Commercial � � � � � �, `'\ � ❑ Irrigation ❑ Noncommunit PWS ,�,�t ( i Y ❑ Remedial w ET i,�i � ❑ TestWell i i i i �� ' � ❑ Dewatering ❑ i _, i -r ��zlM,ia . ' CASWG Drive Shoe? ❑ Yes o HOLE DIAM. _i i i i_ � ❑ Steel ❑ Threaded ❑ Welded i _i_ _i _ _i � O�Plastic ��L1" s �1 Mile� �J/_��,� � !� � - � CASING DIAMETER WEIGHT n PROPERTY OWNER'S NAME � in.to 1 b� ft. IbsJft. �?�in.to��yft. ��P.�,1�;c'3'1'�.�.. .jL!G�II?'e� in.to ft. Ibs./ft. �in.to_lV�ft. Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. 14$S S��I�'?�`i£• Bc:.� RCY:'f`�I SCREEN OPEN HOLE �.f')32�y �,�l.�R.'.y �":Ri 55355 Make a�� from ft.to ft. Type �Y�+ Diam. � SIoVGauze '� Length �� set between j� ft.and 167 ft. FITTINGS: K""�8�IC�I STATIC WATER LEVEL , WELL OWNER'S NAME ��4 ft. [�below ❑ above land surtace Date measured �n$}'��' PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping g.p.m. WELL HEAD COMPLETION �; ❑ Pitlessadaptermanufacturer ��"�`-�`��' Model � ❑ Casing Protection_ ❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? L�Yes ❑ No HARDNESS OF Grout Material ❑ Neat cement ,��entonite ❑ Concrete ❑ Hi h Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from � Yto �3 ft. 3 9 ❑ ds. —r y lri bags from to ft. ❑ yds. ❑ bags Clsy Yelio�T (} 3� from to n. ❑ vd5. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION x�� C�.'�=� rT`�� feet direction type Well disinfected upon completion? L�Yes ❑ No � S:3"'L(3I�I'i1VQ�. Ei�B�j' �O I1� PUMP / ❑ Not installed Date installed 1 D��9� Cl<�y/S,^;:�c1 ��c� 12Ct I55 �ty�rs Manufacturer's name uii�l��'r'�3;'+P,�_ '7�{�i..t��,rj��, ?l' 1 r�c, ��? Model number ��t HP Volts �C Length of drop pipe ft. Capacity ^� g.p.m. Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS y , Does property have any not in use and not sealed well(s)? ❑ Yes ❑'No . VARIANCE v Was a variance granted from[he MDH for this well? ❑ Yes C3�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,etC. The information contained in this report is true to the best of my knowledge. �E��EIV4�� `e�sc�i�g i�rz1l;r.g & ?�,r.t=. S�X'11�Ct?S� �'�b55k . Licensee Business Name Lic.or Reg.No. �� 2 b 1999 ��Qg Authorized Representative Signature Date C;� � C7F ORC�;�'C� �'.��c�� Fe�*�::s:�r � Name ol Driller� Date LOCAL COPY C�� 7� � HE-01205-06(Rev.9/97)