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Home My WebLink Aboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring —� Sealing No. H 14441 � Cou,Tm� WELL AND BORING SEALING RECORD Minnesota Unique No K(n{ Minnesota Statutes,Chapter 1031 or W-senes No. ka4 (Leave blank a not known) Tgta(tship Name Township No. Range No. Section No. Fr eon(sm.--k Ig.) Date Sealed Date Well or Boring Constructed Numerical Street Address or Fire Number and City of Well or Boring Location r J' Depth Before Sealing 11 - ft. Original Depth ft Show exall location of well or boring etch map of well or boring AQUIFER(S) STATIC WATER LEVEL in section grid with-X'. location, showing property ❑Single Aquifer ❑ Muleaquder lines,roads,and buildings. N WELUBORING ❑'Measured ❑ Estimated ❑Water Supply Well ❑Montt.Well E] Env Bore Hole [_1 Other ft ❑below ❑ above land surface W --r --t-- --- --`-- E '• - CASING TYPE(S) --�- - ------------ Steel ❑ Plastic ❑Tile ❑Other mile _ti _ CASING Diameter Depth Set in oversize hole? Annualar space initially grouted? S �. in.from ,�_ to tt. ❑ Yes [3,No ❑ Yes ❑No ❑ Unknown PROPERTY bWNER'S NAME- in.from to It ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown Property or6ner's mailing address 0 /iiteretx'th n e o lion address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑UNcnown SCREEN/OPEN HOLE Screen from to ft. Open Hole from to tt. OBSTRUCTIONS WELL OWNER'S NAME Rods/Dr0 E] p Pipe p E] Check Valve(s) El Debris E] Fill ❑ No Obstruction Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) Obstructions removed? ❑ Yes ❑ No Describe PUMP f Type -.y,,y,,C'' GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO [:] Removed El Not Present El Other FORMATION It 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: Q No Annular Space Exits ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to tt. ❑ Perforated ❑ Redwireb Type of perforator ❑ Other GROUTING MATERIALS) Grouting Material _ from to ft- yards bags from to ftyards bags from to tt. yards begs from to ft. yards pegs 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. Contractor Business alne`' /Licensol Regls6at ion Pio. Authorized Repre"ntafi&Signature'' J , Dab f , H Name qt PersowSea&-4 W6N or Bonng," �-d--'�.- LOCAL COPY 14 HE-0143403 2/97 R WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELL AND BORING RECORD 618575. Hennepin Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Orono 117 23 8 Nw,, S,A Sg, 162. ft 12/2/98 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD 1315 Tonkawa ❑ Cable Tool ❑ Driven ❑ Dug ❑ Auger Xf Rotary ❑ Jetted Show exact location of well in section grid with"X'. Sketch map of well location. ❑ Showing property lines, Wayzata, Mn 55 391 roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? [I YES WO N I 1 ( Baroid quik gel I FROM ft.to ft. USE ❑ Monitorin ❑ V t X Domestic g Heating Cooling _ ?'��^*�^y-(y ❑ Irrigation ElW Community PS ❑ Indust /Commercial ❑ NoncommunityPWS Industry/Commercial W E T ❑ Test Well El IA ❑ Dewatering El r ZMi1e CASING Drive Shoe? ❑ Yes ❑Xo HOLE DIAM. ,G ❑ Steel ❑ Threaded ❑ Welded i i # ❑X'lastic ❑ S �1 Mile / CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME 4 in.to 152 ft. 1.9 lbs./ft. in.to:3P_ft. Jim Render in.to ft. lbs./ft-in.to],-2ft. Property owner's mailing address if different than well location address indicated above. in.to ft. lbs./ft. in.to T ft. SCREEN OPEN HOLE Mffict es a from ft.to ft. Type ;,lactic Diam. Slot/Gauze ti Length_ ioft. Set betweeni ft.and ft. FITTINGS: STATIC W{\ R LEVEL y 12 WELL OWNER'S NAME _ ft.4 below ❑ above land surface Date measured 12/2 PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. 5 ft. after I hrs.pumping 5_Q9.p.m. WELL HEAD COMPLETION ]V Pitless adapter manufacturer Model s 1 45L,- El 5❑ Casing Protection ❑ 12 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? (XYes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement L3Bentonite ElConcrete X High Solids Bentonite MATERIAL from 30 to 0_--_ft. 3 ❑ yds. ❑bags from to ft. ❑ yds. ❑ bags >i d n+",l Aray Soft 5from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION }. 601 feet north direction city pe ty clay .�ra� �a � 5 12 �- Well disinfected upon completion? D.Jes ❑ No sewer clay & sand ; ra' soft 12 14f PUMP ❑ Not installed Date installed Sarid & raved ra y r"ioft 14 162 Manufacturer's name A2rmntQr Model number HP 11/2 Volts 220 Length of drop pipe 6 ft. Capacity 12 g.p.m. Type: ❑fiubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes D"o VARIANCE Was a variance granted from the MDH for this well? ❑ Yes ❑Ao WELL CONTRACTOR CERTIFICATION Use a second sheet,if 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. Leuthner Well Inc. 10125 Licensee Business Name L' or Reg.No. Authorized Representative Signature Date Maurice L. Leuthner 5/24/99 618 5 7 5 Name of Driller Date LOCAL COPY HE-01205-06(Rev.9/97)