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Home My WebLink Aboutwell info . . . . . . _ � . . . . f MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUE WELL , ., WELL C?r�BORING LOCATION AND BOR/NG NO. County Name � WELL AND BORING RECORD ��@p� Minnesota Statutes,Chapter 1031 � � ��}� � Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Oraio 117 23 Q2 ,� ,� ,� „. GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds ',�Cable Tool �Driven ❑Dug ❑Auger �]Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number j� 1Z� DiCR�� VLOEIO SS391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. �tW ilte From ft.To ft. Showing property lines, N _ ��roads,buildings,a di ction. USE Domestic Monitorin � '�( ❑ g ❑Heating/Cooling __J_____1__ ___t__.__:_� ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial �� ' ' ' ' �� ❑Community PWS ❑Irrigation ❑Remedial .� --'----,--- ---`—---'-- �� rl�Elevator ❑Dewatering ❑ W ; ; ; ; E T CASING MATERIAL Drive Shoe? ❑Yes �No HOLE DIAM. _ --;--- --�--- ---�-----<— � — ,. I (�Steel I;!Threaded ❑Welded �. � � � � Mile , � h �Plastic L, '�� - ------------ --.-- ---:-- 1 I I ' ' CASING S .: Diameter Wei htM Specifications �7 Miie—� � in.to �� ft ��Ul Ibs./ft. $'S� "�in.to�ft. � PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. _Ibs./ft. in.to ft. �ert Miller in to ft. Ibs./ft. in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE � �$ $� Make From . To ft. Type $� I1 es� �t Diam. SIoUGauze •Vl� Length� '* �f . Sef between I�I ft.and�� ft. FITTWGS�p p STATIC WATER LEVEL pp Measured from� O4 ft. Below ❑Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)q I� ft.after_ ` hrs.pumping 4S g.p.m. Well/boring owners mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �t�ter I�Pitless/adapter manufacturer Model ❑Casing Protection �12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted f�Yes ',]Na Grout materials ❑Neat cement �Benronite ;]Concrete ❑Other ' From_Q__To_�__ft �_ ❑Yds. �Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From�To�'�_ft. �1❑��j Bags , MATERIAL From To ft. ❑Yds. ❑Bags NEAREST KNOWN SOURCE OF CONTAMINATION fi Il/sand br�l �� j -� _teet �� direction '_�.�C.� : ��---ry�e Well disinfected upon completion? Yes ❑No j._>"` ,d.. � �ia9 g=ay �ofc 3 i18 pUMP $ C�Bv/�� Qr$� �C� �� CO ❑Not installed Date installed ��7___ J O� 1 '� Sch�efer Manufacturer's name ,��1'�C,�e7 �� !t 1 C/� 1 p1 Model Number HP L�5 Volts i321xR1 1 1 �)lJ 101 Length of drop pipe 126 ft. Capaciry g.p.m. Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABA ONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE 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. RECEIVED D°" st°d°la w�ll n`i�.li`� �°., r�. 169I Licensee Business Name , Lic.or Reg.No. QEC 31 2007 " - f 6--2o-0� : i e resentative Signature Cer rfied Rep.No. Date LOCAL COPY 7 5 0 617 � �� — -------- -- Name of Driller IC 140-0020 HE-01205-10(Rev.6/06) T'w i�vv C i�"y ti t�c;a[.t�v' C ' ' , I v��,ci 617 13th Ave So � Hopki is, I\llinnesota 55343 � (612) 935 - 3556___ OS/1 S/2007 Stodola Wel1 Drilling 3841 North Main St. Boni facius MN 55375 938-21 1 ) REPO RT��F WATER ANALYSIS I_z�b #: 166BN Our Laboratory reports these anclyrir.al resulrs, determined on a sample raken by CLIENT on 05/14/2007 from t�e ��ollowi�g location: f2obert Miller 12;Z5� Dickenson ST. Orono,Mn 'JVeli 75U617 Coiiform Bacteria AE�sent Nrtrates Nitrogen <l,U mg/! The vesults of ihese tests indicate tf��at this well is producing water rhat meets the standards for F.H.A,, V q., c�r cnn✓entinnal lor�ns. This rep�rt ,rs an an�alyris f�r coliform and nitrate only and doEs �nci- include analysis ot Lead and other contaminants. (Unless as specifiE d b�� client). Twin City War Clinic, Inc. Bili' an��rsdale I.,�b CertiGceUon:I 0:7-OS3-I I J MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring n C Q�� WELL OR BORING LOCATION Sealing No. H G�)C3 '' County�Jame - WELL AND BORING SEALING RECORD Minnesota Unique Well No. t�� Minnesota Statutes,Chapter 103I or W-series No. F1p}'fM{d('1�„ (Leeve blenk i�not known) �11L�j�.i Township Name Township No. Range No. Section No. Frection(sm.�Ig.) Date Sealed Date Well or Boring Constructed oc�o ii� as 2 i-oo�:� �� 22 r��' o� Q , GPS Latitude degrees minutes___ seconds Depth Before Sealing j / / k. Original Depth ft. LOCATION: Longitude__ degrees minutes seconds IFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ��ngle Aquifer [;Multiaquifer q y � WELUBORING �easured ❑Estimated Date Measured��1� f1�! � ,Water-Supply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring ,- in section grid with"X" location,showing property _��Env.Bore Hole ❑Other _ �ft �below ❑above land surface N �li, s`,�roada,and�b�ulld�s� �CASINGTYPE(S) ,�t ...! --'----'----'-- '-"— . '` Steel [j Plastic 1-j Tile ❑Other _ _ � --'-----�--' """`" ---`-- �� WELLHEAD COMPLETION W : ; ; ; ET ' __;_____;__ ___�_, __;__ � Outside: ��Well House ❑At Grade Inside: ❑Basement Offset �!'M'� �pitless Adapter/Unit ❑Buried ❑Well Pit . --�--- --T-- --�-- --�- ( - ❑Buried -L �Well Pit S ❑Other ��nniie--{ ❑Other PROP RTY OWNER'S NAME/COMPANY NAME CASING(S) ��rt Aiiller Dia tgr i / Depth � Set in oversize hole? Annular space initially grouted? - Property owner's mailing adtlress i(different than well locaiion address indicated above �_in.ifom__�_ to��R �]Yes ��o 'i=;Yes �'No ' '�Unknown 3405 Forrlha�n Cautt � � St tf[7tiilrily� Mt�T 55421 in.fram to R �]Yes ❑No �Yes ❑No �_,�Unknown __in.from_ to ft. ❑Yes ❑No ❑Yes �_;No I]Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r /1 � Well owner's mailing adtlress if different than property owner's address indicated above SCfeen ffom_��to / /c..' ft. Open HOIe ffOm__ to fl. I / / OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) _'�,Debris �,r j Fill ��No Obstruction a Type of Obstructions(Describe)__ ____________________ � GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes �J No Describe FORMATION PUMP x If not known,indicate estimated formation log from nearby well or boring. - - � / TYPe— ---- ��"� � [�Removed �j Not Present ❑Other / -- - � METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: 'j No Annular Space Exists [1 Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from __to ft. ❑Perforated ❑Removed in.from to _ ft. ❑Perforated �Removed Type of Perforator ___ __ _ ___ ❑O[her GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) �r / � Grouting Materi��Q�!L��E.C�/fromr�L__ to�_1� ft. yards_��_ bags 5 _____ _____ 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. Don Stodola Well Drilling Co., Inr. 1691 , ---- --- -- - :: Contractor Business Name License or Registration No. , . ; :' . i% ,...� �/ " ' �..�~-c�J �G l 3 , _ �.- " �._C,� Representative Sig ure Certified Rep.No. Date LOCAL COPY H 5�4 4 7 � � ��v�v 2 Name of Person Sealing WeH or Boring HE-01434-09 IC#140-0423 s/osa