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Home My WebLink Aboutwell info WELL OR BORING LOCAnON MINNESOTA DEPARTMENT OF HFALTH Minnesota Well and Boring i ��1 o f1 A � � --- WELL AND BORING SEALING RECORD Sealing No. H A1 i�.l Co�r,ry Name Minnesota Unique Well No. --- �j �{}�p Mmnesota Statutes,Chapter 1031 or W-series No. � £a.�f 3 LF G �� (�eeve MeMc 1/�wt krrown) Township Name Township No. Range No Section Na Fraction Ism.-►Ig� Date Sealed Date Well or Borirg ConsVuctetl Orana 11 2� �t� 'i�=t303 �=? , -, Numencal Street Atltlress or Fve Number and Ciry of Well or Bonnq Locafion � / ,. �'f 3� � is�k.� �4 V r�� S 5 356 Depth Before Sealing��'� ft Onginal Depih �/ �' ._n Show exact location of N•ell or boring Sketch map ol well or boring AOUIFER(S) STATIC WATER LEVEL m sec6on gnd wrth"X". location, showing property � ingle Aywfer � MulLaqwfer _ lines,roads,and buildings. N , i .� � ELUBORING Measured ❑ Eshmated 0 � � � � ----^� � ' -�� "�� Water Supply Well ❑Monif.Well � � � � ---�---_. --^-. _'r_ _�__ _�" _'�_- . # ❑ Env Bore Hole ❑Other _ _ tt. �below ❑ above land surtace I 1 I I _...----- W -- - -�-- - -- --�-- E ' � j CASING TYPE(S) : r , � , - � � � � � � -�— ' < . ---- - -- —�-- � � r �Steel � Plastic �Tlle �Other_ � � � � tt � -�-- -i— -i-- --�— �ilef� � � ` CASING(S) :'�(+ Diameter Depih t Set in oversize hole7 Annular space initially grouted? �rmrie—a►e �.�s_�-�-.-3 _ ��eT�m.Irom�� to�� R. ❑ Yes ICI110 ❑ �es ❑ No ❑ Unknown i `7S PROPERTV OWNER'S NAME in.from to R. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown �i'A 9I�f8t H �£�� Propeny owner's malGng address If diHerent than well location address indicatetl above. in.irom to fl. ❑ Yes ❑No ❑ �es ❑No ❑ Unknown 2964Q Silver Lake l�l SCREEWOPENHOLE r � �hOC@WOOt�� SN SS��1 � Screen from_..��ro� ft. Open Hole irom lo fl. OBSTRUCTIONS WELL OWNER'S NAME ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill �qNo Obstruction / ' Well owners mei6ng address if ditterent than property owner's atltlress mdicated above. Type of Obsiructions(Describe) Obstructions removed? ❑Yes ❑ No Describe PUMP Type GEOL061CAL MATERIAL COLOR MARDNESS OF FROM TO � Removed �Not Prese�t ❑ Other FORMATION If not known,indicate estimated lormatan log from nearby well or bonng. METMOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE MOLE: 3 �lo Annular Space 6cists �'---�`' �� '�-' �O Annular space grouted with tremie pipe ❑Casing PeAoration/Removal in.from to ft. ❑ Pertorated ❑ fiemoved in.from ro ri. ❑ FeAoreted ❑ Removed Type of perforator ❑ other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.) , �,>,. Grouting Material��fv f �%�f��r�m �_ to�� ft. yards _� bags from to R. yards bags from to n. yaros bags from to_— ft. yards bags REMARKS,SOUIiCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or bonng was sealed in accordance with Minnesota Rules,Chap[er 4725. The informatio�co�tained in Mis report is true to the best of my knowledge. �vn �tt�dola t�ell Driliin� CQ. , Inc. 27172 Contracfor Business Name License a Regisfretion I'ro. --�r7 /'.'"_= - �� . � /d'�%. ,_ � _..�v. -� ., �':... � ,.y z e sentative Signaltlre Dete --y„ � _ '._. . ..J;..,r...,`�. 2�� Name o!Person Sealing Wel1 or Bonng LOCALCOPY H f � - rw� c�y w�-� c � � , 1�,�. 617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556 09/OS/200Z SLodola Well Drilling 3841 North Main St. Bonifacius MN 55375 938-21 1 1 REPORT OF WATER ANALYSIS Lab #: 894 Our Laboratory reports these analyticAl results, determined on a sample iaken by CLIENT on 09/04/2002 from the following location: 19600 Silcer Lake Trail Shorewood,Mn Unique Well #677891 Coliform Bacteria <1/100 ml Nitrates Nitrogen <1.0 mg/1 The resulis of these rests indicate that this well is producing water thar meets the standards for F.N..A., V..A., or conventional !oans. Thic report is an nnalysis for coliform and nitrate only and does not include analysis of Lead and other contaminants. (Unless as specified by client). � 'ti Water Clinic, Inc. \`, BiN �r, �le , � Lab Certification#027-053-I 19 _ � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD f �,� Henne �Q Minnesota Statutes Chapter 1031 "..` ^� ( � J �. Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed n OrOnO 117 23 OS ,. - ,. 112 8-29-02 House Number,Street Name,Ciry,and Zip Code of Well Location or Fire Number DRILLING METHOD / L C7 Cable Tool ❑ Driven ❑ Dug 3'i 3 5 �+ La A� S t 0��Tl� 5 5 3 5 6 C� Auger �Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch ap of well location. ❑ _ a Sho �ng property lines, - - - ro s and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �fVO N /� i i i i � bQQt�jj�,te' .FROM____ ft.to ft. -i -i- -i- -i- USE ❑ Monitoring ❑ Heating/Cooling i i i � Ff��Domestic -'- -�- -�- -'- ,❑ Irrigation � CommunityPWS ❑ Industry/Commercial i i i i ❑ Noncommunity PWS ❑ Remedial w e T ❑ Erniron.Bore Hole — — i i i i ❑ Dewatering n i r i r �/zIM1e ��..-��_� � CASING Drive Shoe9 ❑ Yes �No HOLE DIAM. _i i i i_ � ❑ Steel ❑ Threaded ❑ Welded i _i_ _i _ _i ,, O�Plastic ❑ S ' p '`)�� --1 Mile-� '.J�, CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME __ !�in.to��l{ft. ��Q1 �bs./R �in.t�ft. �as�a �� in.to_ _._ft _._ Ibs./tt. _in.to ft. Property owner's mailing address if different Ihan well location address indicated above. __ in.to R ___Ibs./ft. in.to ft. 196Q0 Silver Lake 1�1 SCREEN OPENHOLE Shorewood, MN 55331 Make Johnson __ ,�om nfo ___n. Type�l�i�.gs��_t�e��—Diam. SIoUGauze� Length (}� ,�_�_ ..__ Set between ft.and fl. FITTINGS: STATIC WATER LEVEL p—qA WELL OWNER'S NAME __��ft.6Ybelow ❑ above land surface Date measured�� r PUMPING LEVEL(below land surface) L Well owner's mailing address if different than property owner's address indicated above. .._.�Q�_ft, after_____��hrs.pumping 9� g.p.m. � WELL HEAD COMPLETION L � r�yI'Pitless adapter manutacturer ��i�t e WA C e C Model .. 'LJ Casing Protection _ __._ ___ �2 in.above grade ��. Cl At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Wellgrouted? f�Yes ❑ No % HARDNESS OF Grout Material �l Neat cement ❑ Bentonite ❑ Concrete Hi h Solids Bentonite k ' GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO /� 9 from y__.to��ft. �� ❑ yds. �bags from _to__ R _____ C7 yds. ❑ bags from . . _to_____ ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATIO� __ )_ feet ��____direction � � i•.�-_ type Well disinfected upon completion? C]/S'es ❑ No �,„ . . � i; PUMP �l Not installed Date installed _Zg� �w�q��2 Manu(acturer's name _��rmo.t_Qr_ _ _- - Model number . _. _.___ HP �_4 Volts 11� Length of drop pipe /� fl. Capacity __ _._____g.p.m. �.i-�-.--. Type: , ubmersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ ABAN ONED WELLS Does property have any not in use and not sealed well(s)? :� Yes GLNo l� VARIANCE Was a variance granted from the MDH for this well? es �,-1 No TN#��,�_ WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etC. The informstion contained in this report is true to the best of my knowledge. D�t�__�..L�s3�18 WQl IT)rillixtg_r�_T. Inr__ __27 72': Licensee Business N e Lrc.or Reg.No. r' �� 'l 1z-5-o� '��E?!��'"qtii zed ep e Date --- --- � �A A�� Name ol nller ate LOCAL COPY � � 7 8 91 HE-01205-07(Rev.?J99) IC#140-0020