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Home My WebLink Aboutwell info DEC-16-99 THU 9 :39 Lll_rh1 STODOLA r v WELL CO. E,1 293801 54 F'. 02 WELL NOTIFICATION -WELL NOTIFICATION IS VALID FOR 18 MONTHS. 639142 Send notilicatfon form and payment (check, money order, or teadit card Information) to: MinneSola Unique Well NO. aUnnesota oepRnmrnrorNae++h,wetl M,.r,■gerrra»l 6xrfon,P.O.8or6d975.Sr.Paul,MlnneFafa 55164•OilfS. ' Credit Gaid Type: 1-7 Visa C1 Maetercaird Exp.Dale .— ATTR:CASHIER I l F.empt Iran paylna fee ❑Yes - Print Cardholder Name an walp,,r Supply W ll l:rrdil Gard Number — h..<;kwclllype dleFamiiy!Olnnr_. —_ .--- ( . nmmuniL FWc(4924) Autharlced�ignA.ture. ❑RemedVel(4;125) ❑Cxnmunily PWS pa 622) p NGnc. y. _ Ll Dewaleriny Well(a) Total number of dewaloring wells _ 2ir/Well-1 to 4 wells(4873) D$8OO!6i19-5 or more wstl!�(4861) I C.>.my 70i'+ru�pp Nyrcp Tmwn:hip NG Rnn9�DN 9mrtlmn v. F•."iM Hetzrl.eU`in oron4 117 23 08 +• WELL CITY a :r4a zipdo fr.r+„mtar LOCATION well L4:iii.: A1,11.11114 pryYrim Yclophje.0 NJRWar w.n owner Wr",.(t'rmq Erotas BuildinR Cor ' ) Sl�ie ZiD Cola . CIIY WELL wl a ow%r Sired AtJ&tls OWNER Cele wn Uwn.r ilY'"I�r poli)) F r,'iii� L679n[.m lin. WELL Will ccnUmClor( -- Ge . .�Q 2 717 2 CONTRACTOR Don S'Codola WE11 Dril 2-16- 9 F■livre It prevlee Proper notification and fee prior 18 tea ppinnlnq of well construction is a vldallon of Wrinesolia 5 Lea,Chapter 1891, )nay result In IM a■■�ermnl o}en edmintakellve penally. WELL SEALING NOTIFICATION-WELL SEALING NOTIFICATION IS VALID FOR 18 MONTHS MinneGala unique Walt Nn Ur W-serla5 No (ingvtt mora.a not MII11lea01d Well and Boring S9allny Ho. knawi�) Send notification form and payment(check,money order,or credit card Information)to: - — Minnesota Department of Heahh.well Management Section,P.O.Box 64975,SL Paul,Minnea6la 55164.0475. C _ �H V 3 16 ATTIV:CA9)41ER Well Management Section Fax Number:(651)215-0978 Credit Gard Tyle.: D Visa O Mastercard Eup.Date x ni lhorn -a In fee OYe.. a - _ Print Cardholder Name R;'.1LChard A■ StOdola Ee pY B - --' — ^ Well Sealing Notit. .gtipn Ghdr:k W li lypa: credit Gard Nuniht.< — at6r'SUpI?ly Wt311' U Morillitring V ell ❑Olhor butliorizetl Signature - -- -' _ County - -- Township Namti Township No. Range No. Section NO Y Fracliori(%Mr -Ig.) WELL Ier)nepin __�Orono 117 _ 2 ��$_ tfs "" 114 LOCATION Wall Location Addrrr5t City Stale Zi' Code Firo Nurrd:wr EsI Deplh Casing Diarrietar 905 Tonkawa Rd Orono ` _ �' V �,. . Weil Owner Name(Prim) Daytime Tuirphone Num bet WELL 1fJell Owner 51rea1 Address Gilt' �taie Zip Coda' OWNER 3436 40th St,. NE 8,Lrf o o-. . ' 55313 Well Owner Signature Dale WELL —~ -- Liconsed or Raglalered Cont,;x lot (Print) G r r F Dal9, Llr.pr Reg No. CONTRACTOR DonStodolaStodola Well Drill n 2-1G�9 27172 F&➢;n'e 10 provide proper Identlllcation and five privy 1,the beglnning or well aealin is a on of inn a Statutes,Chapirar 1031.and may ffi8ult In the'e5sessnien1 of an admini-Wative penally,Noli iration is not roqulreA t0."sl a boring. .-. ' 1 4 1 1 1 A. MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H +f /�20 WELL OR BORING LOCATION _ �� AND BORING SEALING RG�OI"ID Sealing No. 1 3 County Name Minnesota Unique Well No. Hennepin Minnesota Statutes.Chapter 1031 or W-series No. iLeeve dank it not known) Township Name Township No. Range No. Section No. Fraction Ism y Ig.) Date Sealed Date Well or Boring Constructed Orono 117 23 0& 21-0.[12 Numerical Street Address or Fire Number and City of Well or Boring Location 905 TonkaWa, Orono Depth Before Sealing M Original Depth '7 _ f Show exact location of well or boring FF} Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL in section grid with"X F( location, showing property ile Aquifer n A lines,roads,and buildings. g q [-1 Multiaquifer ,;,/ N x WELUBORING L,O Measured ❑ Estimated +t Water Supply Well ❑Mont.Well J� (�^f ❑ Env.Bore Hole ❑Other It below ❑ above land surface W -- - - -- - -- -- -- E i CASING TYPE(S) I I - - -i-- -i-- --i-- :> Steel E] Plastic E]Tile ❑ Other_ Ylmae - ---- - i t CASING(S) ,:.� Diameter Depth Set in oversize hole? Annular space initially grouted? S � � �c--- /�4,, Yes o ❑ Yes ❑ No ❑ Unknown I r mne in.from tom± ft. ❑ -71 PROPERTY OWNER'S NAME - infrom to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown Property owner's mailing address J different than well location address indicated above in.from _ to It. ❑ Yes E]No ❑ Yes ❑ No El unknown 3436 40th St NE SCREEWOPENHOLE Buffalo MN 55313 , Screen from to h. Open Hole from to ft. OBSTRUCTIONS WELL OWNER'S NAME . ❑ Rods/Drop Pipe ❑ Check Valve(s) E] Debris E] Fill ❑ No Obstruction Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) `}" f✓ Obstructions removed? [9/Yes ❑ No Describe PUMP Type :! Z , GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other FORMATION If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: Iii Annular Space Exists ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal infrom 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 lbs.) Grouting Material�,i if from to ff. yards _.- bags from to ft. yards bags from to ft. yards bags from to_ ft. 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. Don Stodola W+ellDrilling Co. , Inc. 27172 Contrc(or Business me License or Registration rio. 1-18-00 Auth zed en ative Signature-" Date Tien Sterner JH 163207 6q207 Name of Person Sealing Well or Boring