HomeMy WebLinkAboutWell info STATE OF MINNESOTA DEPARTMENT OF HEALTH
1. A o WATER WELL HECOHD �N/NNESOTA UNIQUE WELL NO. !
County Name t o�o iJ�
� ..��r a... Minnesola Slalules/56A.01�.08 /%Wafer Samp/e
1"�;.S 4IE..:1XF
Township Name� ownship Number Range Number Section No. Fraction 4.WELL DEP7'H(completcdl Date of Completion
.. . l.1 r ° _. ° �".- i'" y �i `t` � ,
w �i ;�-� 1-� ' n. r-
Numerical Street Address and City of Well Location or Distance from Road Intersection. 5. DRILUNG METHOD
.�. ❑Cable"1'ool ❑Reverse ❑Driven
❑Dug
��,v - �-� r��._ .
' .(.k�..�C 11.�. h' � v. 't cJ:. ��.: -'CL '���.._� t'Li1_i t. � � :7.,�
ow exacl location of well in section grid with"X." Sketch map o(well location. ❑HollowRod ❑Air ❑Bortd ❑
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� � 1 _i_ Addi[ion Name ; � �� -�� � �� C7�Ro[ary ❑Jetted ❑Power�Auger
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� ' .... . �� 6. DRILLING FLUID ��
�
--+- -'- �- �- Block Number � ... . .
W � ; i E 7. USE
i
_1_ _1_ _'_ __ T . � �Domestic ❑Monitoring ❑Heal Pump
1 ' � � . Lot Number
' f,m�. �..,..,. ❑Irrigation �O Public O Industry
� � � L]Test Well �O Municipal O Commercial
--�- �� - -r- - ❑AirConditioning ❑
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I mile—� 8.CASING HOLE DIAM.
2.PROPERTY OWNER'S NAME Mailing Address if different than property address ❑g�a�k ❑Threaded HEIGHT:Above/Below
� - indicated above. Surtace tt.
�:L�:� +i ". . _._... ❑Galv. ❑Welded .. .
Drive Shce? Yes�°.� No— il 1f r-����
,b+ Plastic ❑
r
'1 in.to �`' ft. Weight�IbsJtt. �n. to•�t.
3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to (t. Weight Ibs/tt. �n. to_�t.
FORMATION
' y t"'
in.to (L Weight IbsJft. �n. to—It.
-, ,iiii� 9. SCREEN Oropen hole
Make +'L���11i:��.1'11 trom (t.to. (t.
il:i :3, T :,L_-ir.�e� .:d-.. �;r�
.1...`;'"1 YPe '.'`1 D1am.- _.
1;: - _
SbVGauze Length •-
- � FITTINGS:
Set hetween •����%- ft.and 1.'": ft.
]0. STATIC WATER LEVEL
fL O�below ❑above Date Measured `'��-"�-��
land surtace
11. PUMPING LEVEL(below land surface) �
tt.atter ��- hrs.pumping �i+ g.p.m,
'';�� (t.after hrs.pumping g.p.m.
S
12.HEAD WELL COMPLETION �
:L]Pitlessadapter manutacturer �_'��'1'��"'EY i"j�'����-„'y;� Model
IO Basement of(set :�At least 12"above ground
❑Plastic casing protection
13. WELLGROUTED? J�Yes O No
1� >;,O Neat Cement ❑Bentonite L7
Grout material (rom -�i-' to (t.cu.yds.
p�G
' r � 14. NEAREST SOURCES OF POSSIBLE CONTAMINATION
(ee[ direc[ion �yce
Well disin(ected upon completion? i�A Yes ❑No
15. PUMP
Date ins[alled -�=����-�.` � ❑Not installed
Manufacturer's name��?�'�_
Model number ' HP_��Volts -
Length of drop pipe ft. Capacity �,� g.p.m.
Material of drop pipe.y�� l a=o��c.��
Type:s�]Submersible ❑L.S.Turbine C]Reciprocating
OJet ❑Centritugal L7
16. ABtWDONED WELLS
Unused well on property? G�yes ❑No
Use a second sheel,i/needed Sealed .'� Permanent ❑ Temporary ❑ Not sealed
17.REMARKS,ELEVATION.SOURCE OF DATA,etc.
• 18.WATER WELL CONTRACTOR CERTIFICATtON
This well was drilled under my jurisdiction and this report is true to Ihe 6es[of my
knowledge and beliet.
e A _� :`tl/��'«i` k�;'.;�.�,. �iC.�.�yi��.i�'„�.'r ..i.%. � �e�
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Lirensee Business Name License No.
. . : _ -- , , , -. . -
Address -�-� ��:� S ��iz:?:�. :; i� irt"1`�%'.«.r .-:�i��i •`' `".`
. � .:� r'� �' ,r' .
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SiS�ed � � -'�r��f �/ J ``�.;,r'- Date�„ . . _
��j -���....
Authortzed Represenmttue
. . , i' ;::�;.�.`i���.... DatP ... ...t-,M�-.'.
Name ojDrilfer
G050H7 5„°�"
IOCAI COPY 77630"'
�ne 3onn
HE-01205-03(Rev.9/88) yi82�p�,�
?�r�c L'� ?�Gfart� L'l�e,r�c, ��cc.
617 /3th AVE. 50. • HOPKINS,MINNESOTA 55343 • 935-3556
Stodola Well Drilling February 15, 1990
15306 Highway 7
Minnetonka, Mn. 55345
REPORT OF WATER ANALYSIS
recetved trom you �'ebuary 7� 1990
Our I�boratory reports th�s�analytical rasuita,determfnsd on � sample on
tsk�r-�s
Well water
from
Walt Wittmer
1420 Baldur Park Road
Wayzata, Mn.
Unique Well #505087
Bacteria (Coliform group) less than 1/100 ml
Nitrate nitrogen less than 0.1 mg/1
Conductivity� Specific 460. micromhos
The results of these tests indicate that this well is producing water
tiiat �ueets the �candarcas fur F.H.A.� N.A. , or CG11VeI1�lUIld'L loans.
�ii.� ' y Water Cl.inic, Inc.
, � .� �
�
Bill a A� d le
Analytical I�bontory Consul:inp�nqln���
Wat�r a�alyN�n�p�nts Boiler wN�r eh�qycals
17.1 pa►tslmillfon�quals t.0 prainlpallon
Minnesota Well and Boring 3 6 0 5 8
we�� oR BORiNG�OCn7ioN MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
�o���Y Name WELL AND BORING SEALING RECORD Mi��esota u�iq�e No
Minnesofa Statutes.Chapter 103/ or W-series No.
�'lE;,t�����1 - � �Leave blank d nol knowm
Township Name Township No. Range No. SecOon Na Fraction(sm. �Ig.) Date Sealed Approximate Date We�l
CxC�� � �� G.� {J� 4 r4 Ia ( .,� 1 �,r� � or Boring Cons�ructed
�'f j �_�
Numencal Street Address or Fire Number and City of Well or Bonng Location
C
'�(�,� � Depth Before Sealing ,���� ft. Original Dep�h � � ft.
�.�Lt� �tn"'?{ 7 -t Q`
Show exact location of well or boring Sketch map of well or bonng StaGc Water Level Accurate
in section grid with��X�. location.showing property hnes, _
oads.and bwldings. ❑Approximate
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� � � �
__ _-_ _-_ __ �
7�+ Single Aquifer ❑Multiaqui�er tt. � below above land surface
i i i i
-'- -� -i- -�- A G TYPE
W i i i i E
� i � � `
-r -�- -r- -r 1'_._._._..
i i i i Steel ❑Plastic ❑Tile ❑Other
mile
_� � I �_ �
_ _—_ _i _ _I
/ 1'
S - Screen from �` to �� it. Open Hole from to ft.
�--1 mile--►I -. �-� - � F' `'��� OBSTRUCTION/DEBRIS/FILL
❑Obstruction ❑Debris ❑Fill
PROPERTY OWNER'S NAME
VF+ixk F�,; 1y i;-+-,,.r. <
�'` Type of debris/obstruction �� ��-'�� t'' ������ � ' '�1
Mailing Address d drf(erent than property address indicated above.
Obsiruction/Debris/Fill removed? es ❑No
PUMP �
❑Removed Not Present ❑ Other
CASING
GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depth Se�in oversize hole? Annular space initially grouted?
If not known,indicate estimated formation log from nearby well or boring.
i
��� in.from r�� to � tt. ❑Yes �o ❑Yes ❑No ❑Unknown
drift 0 I
in.from to f�. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
o Annular Space Exists
nular space grouted with tremie pipe
'--� ❑Casing Perfora�ion/Removal
' in.from to ft. ❑Perforated ❑Removed
in.from to fl. ❑Perforated ❑Removed
Type of perforator
,
❑Other
GROUTING MATERIAL
'� ` e
Grou�ing material �\ A--.;,� t.�Y�_.�,�C from �to �"�ft. yards �bags
from to fl. yards bags
REMARKS,SOURCE OF OATA,DIFFICULTIES IN SEALING
from �o ft. yards bags
��� � ���� �� ��� � from to ft. yards bags -`
1 be,g Ce�ent
� �� ��~j te UNSEALED WELLS AND BORWGS -
iAli
fp.��� Other unsealed wel�or boring on property? ❑Yes No
Z R� 1�� r� C� C�t �`��t � LICENSED OR REGISTERED CONTRACTOR CERTIFICAT N
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
irue to the best of my knowledge.
!.'t,}I�Y : l�,'�.X_.�.ES �i��.� rl�l.��.waY� l�l�w r �_Ik{..�w !'r J /t:
Contractor Business Name License or Registration No.
f
f;=:=-'=� ./ :-;�"��� t�3
thori� d Representative Signafure � Date
LOCAL COPY I„I '�,irn i�xelrA
Name ol Person ealing Well or Boring
HE-01434-01 -