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Home My WebLink AboutWell info MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring �� WELLOR BORING LOCATION WELL AND BORING SEALING RECORD �aling No. �H_ Counry Name Minnesota Unique Well No. -- Mmnesota Statutes,Chapter)031 or W-series Na � � @�lY]ep 1� 0.seve mnx n oa k�ow�� Township Name Townsh�p No. Range No Section No. FracGon�sm.-s ig.) Date Sealed Date Well or Bonng Constructed rono 117 23 Ofi 2�1-�00� 2� v�},� Numerical Street Adtlress or Fire Number and Ciry of Well or Bonng Locahon . i�8� B�i/f3�{�Q �i()�j�� Q;'0�(� Depih Before Sealing �� r it. Original Depih � �� ' h Show ezact Ixation of well or bormg C G Sketch map of well or boring ApU1FER�S) STATIC WATER LEVEL in section grid with"X'. 5 J 3 J 9 locat�on, showing property Single Aywter � Multiaquiter li es,road�s,an bwldings. - N � � . �,y ��.� WELUBORING .�Measured ❑ Estimated -- - - -- -- -- -- -- � '... �Water Supply We�l ❑Monit.Well � �� ❑ Em.Bore Hole ❑Other _ ��ft. �below ❑ above land surtace W --�- -i-- -i-- —i— E �� CASiNG TYPE(S) � � � , D � � � � �. —�- -i-- -r- --�- � (�Steel ❑ Plastic ❑Tile ❑Other Ylmile T —�- -i-- -i-- --i-- I CASING(S) � �� Diame/1er' Depth � Set m oversize hole9 Annular space initially grouted? l S J� [�.! ,/�,y/C� �i mae—�1� � in.from O to I�1 tt. ❑ �es �No ❑ Yes ❑No ❑ Unknown I UOPeERT�O�uE�R'SNAM�52_747—�GG� in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown tl V V Property owner's mailing address it ditterent than well localion address indicated above. in.from to tt. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown SCREEWOPEN HOLE ♦�� r � Screen hom L�S.L ro��.ft. Open Hole irom to ft. OBSTRUCTIONS WELL OWNER'S NAME �Rods/Dro Pi /'') p pe ❑ Check Va�ve(s) ❑ Debris ❑ Fill ❑ No Obstruction Well owners mailing address if dilferent than properry owner's atltlress Indicated above. Type ot ObslruCtionS(DesCribe)��/ti �/�� ¢ / Ur' ,� Obstruclions removed? Yes ❑ No Describe PUMP h Typg SVQ� ! �R9 �� 6EOLOOICAL MATERIAL COLOR MARDNESS OF FROM TO emoved ❑ Not Present ❑ Other FOHMATION If not known,indicete estimeted fortnatbn bg from nearby well or bonng. METHOO USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists � -� r� ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal in.from �e ry. ❑ PeAorated ❑ fiertroved in.from to tt. ❑ PeAorated ❑ Removed Type of perforator ❑ Omer GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) `�'7 J i Grouting Material /�L A/ C�/�s.'�r6m �_ ro L�G51 tt. yards �bags irom to fl. yards bags trom to fl. yerds begs from to__ tt. yards , bags REMARKS,SOURCE OF DATA,DIFflCULT1ES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes o How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 0725. The infortnation conteined in Mis report is � true to the best ot my knowledge. _ DonbSt�dola 63e21 Drilifn� Co. , Inc. 27172 Confractor Business ame License or Registrafion I'io. i ~ � // � {� r�� ^.�+f uth ed R resentative Signeture Dete LaCAI CO�Y H �Q��Q Z Name ol Person Seeling Well a Boring 6d - � � ,- / MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. WELL LOCATION ' CountyName WELL AND BORWG RECORD 6 5 5 0 3 2 Henne in Minnesofa Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n. ; Orono I 1 �3 �� °�� 2 3 House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug � � ❑ Auger �Rotary G Jetted Show exact location of well in section grid with"X". Sketch map of well location. ❑ ___.__ _ .. /� (�J ,..�howing property lines, _ f�A/ s'�j'1�! l'�J ) roads and buiidings. DRILLING FLUID WELL HYDROFRACTURED? ❑VES �NO N � � � � � FROM n.to n. -,- -;- -,-- -,- -�....�_� �~ USE C Monitoring ❑ Heating/Cooling i i i � �Domestic � ❑ Community PWS ❑ Industry/Commercial -�- -�- -+�- -i- ,� Irrigation i i i i ❑ Noncommunity PWS ❑ Remedial _ yy E T �] Environ.Bore Hole � i i i � , ❑ Dewatering ❑ i -, i i '/ZIM1e x CASING Drive Shoe? ❑ Yes �No HOLE DIAM. _� i i _�_ � / / ❑ Steel ❑ Threaded ❑ Welded i i i i �M1/G�G,. �Plastic ❑ S �1 Mile� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME __�b in.to__�_'��_ft. __a_�_�S Ibs./ft ��n.to�tt. ___ in.to _. ft. --_.--- IbsJR in.tOf"1 J.ft. in.to__ ft. Ibs./ft. ��n.to ��{ft. Property owner's mailing address if different than well location address indicated above. — - - ------ 4100 Berkshire is�Qe SCREEN�t� OPENHOLE PI mouth MN 5544b Make_�ns—_, steel �'°m .___"`° n. Y � Type ��Z�i��s Diam � SIoUGauze ��_l_V Length Set between ft.and tt. FITTIN S � STATIC WATER LEVEL WELL OWNER'S NAME --_IZ_a__ ___—ft.�.below ❑ above land surface Date measured_'��_�' �� Q PUMPING LEVEL(below land surface) � ' ' Well owner's mailing address if ditterent than property owner's address indicated above. �.2�_,.__ ft. after , _.__ 2 hrs.pumping �_g.p.m. �� WELL HEAD COMPLETION �PiUessadaptermanufacturer V�'1'� }AVAtA1'._ MOd21 ❑ Casing Protection _._. .. __. �12 in.above grade - ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �l Yes ❑ No HARDNESS OF Grout Material C' Neat cement ❑ Bentoni�e ❑ Concrete High Solids Bentonite GEOLOGICA�MATERIALS COLOR MATERIAL FROM TO � from___�to___��. ___.�.�_�❑ yds.,,�bags from to_ ft. bags topsoi2 blacic aft 0 3 —�- �� °tar-��_��P from_ to ft. � ds ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION � CIa� yellow �l� � 3� f�-� feet -> i'i _� : ri� _direction Sc�eTrype Well disinfected upon completion? tGl Yes ❑ No l" cl$y/boulder gray edium 38 15� P�MP ` 4 ❑ Notinstalled Dateinstalled __ 12��1�Q� _- r4 o . _ _._._.__. sand, fine g�$y Olt �S� 1Q0 Manufacturer'sname ---C��de— _- - _ __ Model number HP Volts ��11 clay brovn ediu� 180 220 � � Length of drop pipe__.��_�_ fl. Capacity ______ __g.p.m. sand/gravel brown �ft 220 23t� Type �Submersible � LS.Turbine ❑ Reciprocating ❑ Jet ❑ __ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes y�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes �YNo TNri WELL CONTRACTOR CERTIFICATION Use a second sheet,if needed 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. REMARKS,ELEVATION,SOURCE OF DATA,etc. ' �-� �rC��— . 9 ---� 71 1(. Licensee�ess Name Li. r � , . �. .C , ��n n _ _ _ �� Aut~orrzed e sen ive ig��e --�-� � Dafev— Chuck Moore 11-29-00 -- _ _. ____ , 6 5 5 0 3 2 Name o�Driller Date LOCAL COPY HE-01205-07(Rev.2/99) . ru ►� c�-y w�� c � � , .��,� 617 1 '�th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556 �2/0�/2000 Stodola Well l)rilling 3841 North Main St. Bonifacius MN 55375 938-21 1 1 REPORT OF WATER ANALYSIS Lab #: 682 Our L�+boraiory reports rhese analytical results, deterrnined on a sr�mple taken by CL1�:NT on 1 1/29/2000 from the following location: Tony Eiden Company 4485 Bayside Rd Orono,Mn Unique Well #655032 Coli form Bacteria <1/100 ml Nirrates Nitrogen <1.0 mg/1 The results of these tests indicate that this well is producing water that meets the standards for F.H.A., V.A., or conventional loans. This report is an analysis /or colifcrm and nitrate only and does not include analysis of Lead and other contc�minants. (U►�less as specified by client). 'ty Water Cl,nic, Inc. ��' \ Bill �Q s le � Lab Certification#027-053-119 .