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Home My WebLink AboutWell info MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. Ce�nty Name�� WELL AND BORING RECORD Minnesota Statutes,Chapter 103I �5'l��4 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED v< v< v< 1�! n (.�"13"'Q7 GPS DRILLING METHOD LOCATION: Latitude degrees __ minutes seconds ❑Cable Tool ❑Driven ❑Dug Longitude degrees minutes __ seconds __ I Au er �Rotar � � g � y ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � � s DRILLING FLUID WELL HYDROFRACTURED? ❑Yes�Na Show exact location of well/boring in s tion grid with"X" s �1 map of well/boring location. �t�ite From ft.To ft. Showing property lines, � :i N �r6�,buildings,and direction. USE �Domestic 'L]Monitonng ❑Heating/Cooling ,� __j___ _�____�_____L t ❑Noncommunity PWS j�Environ.Bore Hole ❑Industry/Commercial � 1 _�, j ! L i � �%` ❑ ommun y WS �Irrigation ❑ emedial , C it P R ,: , --;---- , - , L, ❑Elevator �Dewatering ;;. w , , , ; ET�� °�` CASING MATERIAL Drive Shoe? ❑Yes �j� HOLE DIAM. � --;--- --�----F—--%-- �� I � . ��'�''� ❑Steel ❑Threaded ❑Welded ...- � � , � Mile � � , , , , � ��' � �`i f�'�Plastic ❑ �• --�--- --T----�-- --�- � -' �% CASING � S � -�=� Diameter Weight Specifications - F--1 Mile—� � �in.to��ft. �_Q Ibs./ft. �!� �in.to '�ft. %':'�*-� . PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. �in.t�.g1�ft. Tt�/Lpr�et te �rI18� in.to ft. Ibs./ft. in.to ft. �� SCREEN OPEN HOLE ' Property owner's mailing address if different than well location address indicated above. g�� a� gt�� Make From ft. To ft. ..r�.7.. UUYC � Type Diam. t SbtlGauze p•� Length � ';' Y* 10't �ft. FITTINGS � � Set between ft.and STATIC WATER LEVEL Measured from 3� ft. Below �j Above land surface Date measured �� WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 17� ft.aRer 1.J hrs.pumping �� g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer�.l��- �-= � ""'��nJlodet� ❑Casing Protection �2 in.above grade �� ❑At-grade(Emironmental Well and Boring ONLY) GROUTING INFORMATjON z Well grouted +�Yes ❑No Grout materials ❑Neat cement�(Bentonite ❑Concrete ❑Other From�To�R _� ❑Yds. �n Bags - GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From�To��_n$�j]�_,��x�]Yds. ❑Bags MATERIAL From�To ❑Yds. g Bags NEAREST KNOWN SOURCE OF CONTAMINATION �j ' � feet direction - ' -� �'type � ' Well disinfected upon completion? f�7j Yes ❑No ,;.� _ t__.�---':-._-��- c�._ PUMP � ra ❑Not installed Date installed � f <� � � 11� Sf�t�`�� ft � �'1Q3 1ltJ Manufacturer's name — i�.... ^' i'�'' "--� ! Model Number � HP�Volts clay/rocks gray �i� 1S0 176 - Length of drop pipe �/G—� ft. Capacity g.p.m. � �/gr�� l �ft 176 10(} Type: , Submersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑ ABA DONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE i Was a variance granted from the MDH for this well? ❑Yes No TN# WELL CONTRACTOR CERTIFICATION 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. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Dcm Stodole Wel2 Driiling Co,. Inc. 2691 Licensee Business Name Lic.or Reg.No. i -- ,> /--� /�� <� ertified Representative Si na e Certitied Rep.No. Date t�ck i�t�e LOCAL COPY 7 5 0 6 6 4 Name of Driller IC 140-0020 HE-01205-10(Rev.6/O6) rw� c�-y w�-� c � � , r� 617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556 09/17/2007 Stodola Well Drilling 3841 North Main ' St. Boni facius MN 55375 938-21 1 1 REPORT OF WATER ANALYSIS Lab #: 432BN Our Laboratory repovts these analytica! results, determined on a sample taken by CLIENT on 09/13/2007 from the following location: Tom Bernard 3470 Birch Lane Orono,Mn Weli 750664 Coliform Bacreria Absent Nitrates Nitrogen <1.0 mg/1 The resulrs of these tests indicate that this well is producing warer that meets the standards for F.H.A., V.A., or conventional loans. This report is an analysis for coliform and r.itrare on(y and does not include analysis of Lead c�nct other contaminants. (Unless as specified by client). ,-� Twin Cit� Water Clinic, lnc. ' eill V'n �iWsdale ,r � i° Lab CeRi£cation#027-053-]19 �WELL OR BORWG LOCATION MINNESOTA DEPARTMENT OF HEALTH c Minnesota Well and Boring I„I ��A�} = County Name WELL AND BORING SEALING RECORD Menne9oa°u��q�ewe��No. �tr ` � i� Minnesota Statutes, Chapter 103I or W-series No. (Leeve blenk If nol known� Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Conshucted �cio 217 23 08 '' '' '' �Z �.T' �''7 / . GPS Latitude degrees minutes seconds Depth Before Sealing ` �� ft. Original Depth_ ft. LOCATION: Longitude degrees minutes seconds UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location _. ingle Aquifer ❑Multiaquifer cn,y}f /�/� �t7EA pJ� T,d..�,3 /�,.�,�� !!7lf1 WELL/BORWG Measure� ❑Estimated Date Measured J//"'- '�!' ` .7YlU 17`i i�!}� VLG�iJ{7 .7.�37Y �- Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring �j in section grid with"X" location,showing properry � �Env.Bore Hole ❑Other � ft. �elow �_1 above land s�rface - _ N lines,roads,and buildings. CASING TYPE(S) -'----'--- --`-- ---'-- I I � ' 4 . , , , ; �Steel U Plastic []Tile [�Other �� --'-----�--- ---`- ---�-- WELLHEAD COMPLETION ' � W ; � ; � ET ,,..:' ' ' _;-- -_;-- l.. asement Offset �� _ ,_____,___ _ �At Grade Inside: � � Outside: ❑Well House ';;� � � � � M'ie dless A p r/Unit , Buried ❑Well Pit h � , , , , , � U P� da te � :�}:> --�-----�--- --�-- --%-- 4. � . ❑Well Pit ❑Buried S ❑Other �-i nnae� � ` � f� ]Other A..vC..i�. (�/!•,..,..�.� �� P OPE OWNER'S NAM COMPANY f�1ME CASING(S) �am� tte �ernaca Diamet�r� / � Dept'h'� � Set in oversize hole? Annular space initially grouted? Property owner's mailinq address if different than well bcation address indicated above _y�in.ffom V to�R. (�Yes �No ❑Yes ❑No iJ Unknown in.from to ft. ❑Yes �J No ❑Yes ❑No ❑Unknown � a in.from to ft. []Yes ;�No j_]Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � � r Well owner's mailing address if different than property owner's address indicated above SCreen trom �� to /��G+ ft. Open Hole from to ft. �O,/BSTRUCTIONS yY Rods/Drop Pipe ❑Check Valve(s) ❑Debris (�Fill ��,.__!No Obstrudion - Type of Obstructions(Describe)/�J��=��- / _� *' �+_� _._. _ 3 GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? U/Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. �� '� � � � Type U�� Removed ��Not P esent ❑Other a METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exists �-]Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from 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 Ibs.) a,�i<R i f�il�.uT ' j� � �— � Grouting Materi from � to ft. yards bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 4725.The intormation contained in this report is true to the best of my knowledge. � cio�n Stodale Re21 Dri.liing Co,. Inc. I691 Licensee Business Name License or Registration No. $ /�- �.� .c � erti ied epresentative Signatu Certified Rep.No. Date 264278 `�`� � �� !..00r1L COPY H i,�/Y'� _ Name of Person Sealing Well or Boring HE-01434-10 IC#140-0423 5/o�a ±