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wELL OR BOaiNG LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �
Counry Name
WELL AND BORING SEALING RECORD Minn'egoNa Unique Well No.
�n�C fn Minnesota S�atutes,Chapter 1031 or W-series No. i _ , ,
(Leeve blank�i!no�known)
Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Weil or Boring Constructed �5
Orono 117 23 11 32-001(? �� Er-lg-gg
GPS Latitude degrees minutes seconds � �J �
LOCATION: Depth Betore Sealing ��� ft. Original Depth � / fL •
Longitude degrees minutes seconds pn�qFER(S) STATIC WATER LEVEL
Num�e}rLical�rreet Address or Fire Number and Ciry of Well or Boring Location ��ingle Aquifer ❑Multiaquifer
14V5 .��.L•���t8 �i�t �d� 0�� ;��WELL/BORING �Measured ❑Estimated
�� �Water Supply Well ❑Monit.Well �/ I
Show exact location o�well or boring SkeYch map of well or oring
in section grid with"X" location,showing pro � ❑Env.Bore Hole ❑Other �� ft. f�below ❑above land surface
N lines,roads,and build 9ti CASING TYPE(S)
1�
� ��y ` �f �� �Steel ❑ Plastic ❑Tile ❑Other r
� ,>� 4 � T�
� �f;
W — - - -- - — —i— E � � *.) WELLHEAD COMPLETION �--
r , , � '
� � � � � �� Outside: ❑Well House Inside: ❑Basement Offset _
;
-;-- ;-- -�— —�'- , i
� � � �..
yemile �'_..,..-.� ; � [�iUess Adapter/Unit ❑Well Pit ���
� � � � _ j .. 'r
-�-' -i-- -�— —�— � i i . -
-. ❑Well Pit ❑Buried
S
�—�^"�°--�' ��.,� ❑Buried
� ._
ppnoFqry nwNER'c Nnnncir.nnnanniv NAME CASING(S)
1� fy�—� 1
��'�=t` .- �� .�?','f��:,�� � Diamet rt� Depth r Se�in oversize hole? Annular space initially grouted?
Property owner's mailing address if different fhan well location address indicated above
� in.from� to�ft. ❑Yes �iio ❑Yes ❑ No ❑ Unknown
�r
.. s�a_ �.'..�z�,.i 2 s,a �s�,
� ,��.�T Sg347 ift.f�om t0 ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown
t?f��tl x���� . x
9�(,�y���� Ifl.f�om t0 ft. ❑Yes ❑Na ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE �
Well owner's mailing address if different than property owner's address indicated above Screen from t0 ft. Open Hole from-��'t0 ZI'' ft.
OBSTRUCTIONS
(�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe) �/�1V'�,�/�Tf"� * / 1��7�
i
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YBS ❑ NO DeSCfibe
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP
gCEIV@Z � 75 TYPe JV�: t"�L�M�
�emoved ❑ Not Present ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�lo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
`' 98[i�$t0� 1� Z17 in.from to ft. ❑ Pertorated ❑ 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.)
/j�/ �- .-���'7/
_ Grouting Material �����/f" "�/from � to._Sr_i.1_ft. yards _�`jp 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�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.
� gt��lr.�€eil �rilli�-C�a., Inr. 7�
Contractor Business N e �� . License or Regis�tion�
_ ...._ �,,,% -
� ;�
or d Representative Signaturp� + Da e
Jim Anttmson
LOCAL COPY H 215 0 3 5 Name o/Person Sealing Well or Boring �
'. , �
.�.�.: .,:.,:.:�.a..�� . �-. �,: ...:.,�, , ..,.� �.;.. �_a-..,,�:,,.�-_vG- �v_.,._.�.�_..,�.��., �,:.,v,�-��,`.�..,�-.�:.:��,..�-,..���:-,�..�.�.�:•,..,. _.�.�Ya:q
STATE OF MINNESOTA DEPARTMENT OF HEALTH �
1 WATER WELL RECORD MlNNESOTA UNlQUE WELL N0. � � �;+;� �� �
County Name �t���� � Minnesola Statutes l56A.01�.08 I�'Waler Sample t �.>' ..1 ,�
�
,.., - Township Name i ownshi N�yumber Range Number Sectio{�t�o. Fraction 4.WELL DEPTH(mmpleted) Date o(Completion
:).�"!�".��? �i.�l � .x::� or 13�. �i y w t`1/� r�"'�.�y�_.::�
____�' H, ri.
�stance and Direction trom Road Intersection or reet Address and City of Well I.ocation 5.DRILLING METHOD
��C�yC'.: r��,...x;.��i--`� �:r������ : �� �; ����� 10 Cable tool 4O Reverse 7�Driven 1(IO Dug
i�d.
xact location of well in sectan grid with"X�." Sketch map of well loation. z�Hollow rod 50 Air SD Bored 1 t❑
� � � . dition Name , . 3�otary 6O Jetted 9O Power iauger
--r- t -1 - �- 6.DRILLING FI,UID
� �
--+- -�- �- �- Block Number � � �. 7. USE
yy i � I � E
� T - . 1�Domestic 4O Monitoring SC]Heat Pump
_1� _ I
'�'�I ' ' � Lo[Number � 20lrrigation SO Public 9O Induslry
� �fi mi. �
3O Test Well 6O Municipal IOO Commercial
'-�- �- � —r' I 7O Air Conditioning 11❑
� 1
�—1 mile,� 8.CASING . HOLE DIAM.
2.PROPERTY OWNER'S NAME s 3.,�,�+�' .+�_1C1 � �s�. HEIGHT:Above/Below
IO Black 4p Threaded
�.:. �'C3�.�,.S4.�E:..�t,"r Surtace tt.
.�`,':? � r �.- �-'l;I�. �y`.='�� 2O Galv. 5�Welded �
Address �E.�'�-':i+�.:{.�j �.��.r «>�:..{F�1 3pP�astic � �y _ Drive Shce? Yes •J�o—
ti �_i.t. �.�;.i.t.?
in.to ft. Weight 16sJtL �n. to�t.
3. FORMATION LOG FROM TO in.to (t. Weight Ibs✓tt. �n. to�t.
in.ro ft. Weight Ibs./ft. �n. to�t.
�. . y ,-. .M.. ..
c \'��:.L. .... .., ��'�. � ,,
9.SCREEN Or�open�o�?i: �� �
Gom ([.to. ft.
Make
�i''�.� �.� ��C'i TYPe Dis.
SIoVGauze �n�h FITTINGS:
��&�� J���� ��/ Set between ([.and it.
10. S]`qTIC WATER LE�EL �.,,.;�.,_�t�;
tt.O below ❑above Da[e Measured
land surtace
11.PUI1¢PdNG LEVEL(below ianc);sur(ace) --.;
,l: 'x t,u
ft.a(ter hrs.pumping g.p.m.
tt.atter hrs.pumping g.p.m.
12, .EAD WELL COMPLETION .�,].'�,� {����'
10 Pidess adapter.manufa�'urer mode�
� 20 Basement of(set 30 A[leas[12"above ground
4�Plastic casing protection
... . �3.WELLGROUTED?
.�
❑Yes ❑No
:�., !�i*.:.�;;3. ��c:.�.::i.�.I
lO Neat Cement 20 Bentonite 3O
Grout material from to tt.cu.yds.
- 14. NEAREST SOURCES OF POSSBLE CONTAMINATION
feet directior� type
h
Well disinfected upon completion? O Yes ❑No
15.PUMP
�i.�'!C3 �Ji�L:a �� �t:�3.
Date installed O Not installed
Manufacturer's name
Modei number HP Volts
I.ength o(drop pipe ft. capacity g.p.m.
MateriaJpf drop pipe
1�
Type:lO Submersible 3O L.S.Turbine SO Reciprocating
2�Jel 4�Centrifugal 6O
16. EXISTING WELLS �
Unused well on propeQFy? O Yes ❑No
Use a setond sheet,iJ needed ppandoned � Permanent❑ Temporary O Not sealed
17.REMARKS.ELEVATION,SOURCE OF DATA,etc.
• 18.WATER WELI.CONTRACTORS CERTIFICATION
This well was drilled under my jurisdiction and this repor[is true[o the best of my
knowledge and belie(.
:�r:� �:�"�.�';�i�s �.d:., �l.i.►Yl� b..���„t :��� �.r�'�
1<��-�., !e� # �� �t,:�::t� �.��a�w�;,�,A
Address
:;"' �
Signed DatP
,. W �y.a ����y�� Authorized Representative $,,,_�t�,�t�(�
a�
DatP
Name of Driller
LOGAL COPY 4 5 81�6 5/"�
�ns aa�,� �
�i�e�
HE-0120502(Rev.10/85) 2/82 10M �
� _
�iwl�c �� '�'G'�c ��l�irl�c, ��.
617 13th AVE. SO. • HOPKINS,MINNESOTA 55343 • 935-3556
Stodola Well Drilling June 28, 1989
15306 Highway 7
Minnetonka, Mn. 55345
REPdRT OF WATER ANALYSIS
/received trom you\ June 20 r 1989
Our laboratory reports th�s�analytical rasulta,detsrmined on a sample 1 � J on
\ s
well water
from
Michael Lynn
1265 Bracketts Point Road
Orono, Mn.
Unique Well � 458106
Bacteria (Coliform group) less than 1/100 ml
Nitrate nitrogen less than 0.1 mg/1
Conductivity, Specific 325. micromhos
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.
Tw"�� ater Clinic, Inc.
Analyticd labaatory Consul:i�q�nyfnNr
Wat�ranalyslanap�nt� Bl Arsdale eou.►wa�•«n.m�cais
17.1 paNslmflllon�quNs 1.0 prainlpallon �
�
(��� � NT Of HEALTH
� �"`-11�fH011EB-� CORD
� �oc,►T�o�a Ku � �i! MINNESOTA UNlQUE YELL M0.
_ . _. � , (1.•w et•nt tr noe ►noun)
c°""`''"." Henni n � � '
Twns�10 M�r Tam��ty Mu�Etr uwMr S�ctlon No. Fru�t1_oyn�''� �. �Cll DEiTH (co�p1�U!) WU ie�Ld
11/ Sr �r ' � �JO ft. 7/�d/�' /
/
Nurr/u�ir�tt AO�nts �n0 C1tr ot W11 lou r D1tUnc� tro�b�d S. DNILUXG NETM00 (1f knarn)
Intersetttoe 4Clt tool 1�Mv�ra 7[]Dr1wn l�Duy
1265 Bracketts Pt. Rd. , Or'o o �>>a� SOA1r ep�...� i�p
SAw�uct 1a�tlon of w11 x]bUry i0.1�tt�� �]►wtr Auy�r
� (te tuNM yr1�r1t� •S'J � . .. . S1�tc�ry of rll 1x�Nen f. 0lSiIlUCTIOMS
N W11 oDitrucUd T s � Mo
_ � - _ - •_ -` OEstructtont wd T�t �IN If obftrvctlons c�n�qt E�
, . i rwor�. conNct�011
w _ . . . - � �l1�ri N�1feo.
-I- E
' • 4- �. use
• � - � � 1�Do�rstic Q IbnitorlM �N�at lao
, -� yI�.�0• �� l� $ 2(.]7rr1qat1o� �►ub11t �I�duttry
..�. . ... _ .. I ' d
' � ' � � ! '�i ap t.,t w�i e�w���+o�� it�]ee..,�c�.�
r—1 SL— � 7[]A1r CoM1tiMlxy 11�
2. ►RWEATT OYI(E�'S NAIE qilinq AEOresc tf Elfitnet tMn !. USIM6(S)
property �dArus tedluted aeo�. �n,cr �nv..a� �[]
2�G1r. 50 W10N
Mike Lynn Same as Above Address �p r�.�t,� �sa,.�„. su.�
NAADIIESS OF
�. FORMI1TIpl lOG COl01l FWUNTION iRON TO � �a' u �t'
U eot kno�. indlnU far+�tton loy fro�nw wll or n��rEr N11. in. to ft.
f. SC�[G(
UNKIVOWN pq s�...�..t i rr..(4(Q rs. a�rs.
(lf tnwn)
- p ov.■ �o,. r►a._rc. u_+e.
10. STATIC WTEI LML
/(� ft.�O�lw ��Ooq �i
laM � r1�c� Gt� IY�sund��,o�
I1. YEII�IEl�D COIILiTl011
1�►ltlett AM►4r �fwM Mirt�!
• 2�I�f�rnt�1fNt �
_ . x]Wil Ht
{. Rplyii, [L[YATI011, Sql�CE Of O�TA - CASINGS REIIDV[D, CASINCS ►[RfORATEO. ETC.
12. GIIWTING IMFOIIMIITIOM
1�IN�t Cwnt• �M�to�1t� �]
Grout 6" We 11 Approx. 70' Deep °roit"�'�,•' r"°'2"�•`. °°. �"
10 �3ags Cement — —
1 Bag Benonite 13. NGIEST SOIIRCES OF COIfTlU11M+1TI0N
3 HOt1TS Labor _ f••t Hnctton�n�r,c>tx%I'1 tyoe
wii a+�+ni.cua wro� wattn9t �T�s
1l. P1MI [�'M�orea �Not Infe�t
"�
TyOt: �S�WH1►1� ��.5. TY�iM �bctorouc+�a
Jtt �G�tr11w�1 IQ
15. EIISTINi YEllt (►l��t� •t�tcA 1x�tt�ns of�Wndon�a an0
. �tttr� r�ll1 t� rwrkt wctlen or o� Ntk,)
OtMr unuud�w11(�) e� ProryrtyT �T�f Ne
� Ap�nAOMA: �/�rwn��t �Twiy�r�rr (]Not ��1�0
17. YATEII VELL C01fTIGCTORS CEIITIFIUTI011
TMs N11 ws sa1N unNr�y JurUHctiw �n0 thlt nOort
' ti tro� to tM Mtt 0/�y knorldy� uN Oe11�f.
L1t�nN� W�tn�ft Nay Ut�nft Mo.��� �
� ,�,,.,, 15 Mtka Mn 55 5
s,qM wt. 7 24 89
ar dola au 7 24 89
ii1C1►l AIAMOOM[D VLII YEW�D (M�y 0� utfA for �roptrtr Tr�nihr) M�r 01 Or111�r
S�OtlAIlr Illi Q!l L1�
�