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Home My WebLink Aboutwell info wELL OR eORING LOCATiON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 115 6 6 5 County Name WELL AND BORING SEALING RECORD MinnlesoNa Unique No. Henne i n Minnesota Statutes,Ch2pter 1031 or W-series No. P (Leave blank it not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed Oro�fl 11? 23 3 % % % ��9� Numerical Street Address or Fire Number and City of Well or Boring Location 18L� FV�C Street, �Iayz�ta DepthBeforeSealing J�� tt. OriginalDepth ft. �/� O Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL in section grid with"X". location, showing property �Single Aquifer ❑ Multiaquiter q lines,roads,and bulldings. C � `��•� N WELL/BORING �Measured ❑ Estimated �� `.�, � �Water Supply Well ❑Monit Well � - - - - -;-- — — �� iC� ��'f ❑ Env.Bore Hole ❑Other ft. �]below �/ ❑above�suAace n W --f- -i-- -i-- --i-- E CASING TYPE(S) . I I I 1 vy� --�- -�-- -�-- '-�-- � �Steel ❑ Plastic ❑Tile � Other b mile --�- -�-- -�-- --i-- � CASING Diameter Depth Set in oversize hole? Annualar space initially grouted? LLL""" S 1� y�---r miie--�e � in.from_1� to� ry. ❑ Yes `„�No ❑ Yes ❑No �] Unknown I I PROPERTY OWNER'S NAME in.from to R. ❑ Ves ❑No ❑ Ves ❑No ❑ Unknown Properry owners mailing address if different than well location address indicated above. in.from to tt. ❑ Yes � No ❑ Yes ❑ No ❑ Unknown IB�O FOX 3treet SCREEWOPENHOLE Wayzata, MN 5539I�9�� Screenfrom to ft OpenHolefrom�ro s-'�f}`'_ ft. OBSTRUCTIO WDEBRIS/FILI WELL OWNER'S NAME ❑ Obstruction ❑ Debris ❑ Fill � No Obstruction Well owner's mailing address if ditte�ent than property owners address indicated above. Type of Obstruction/DebriS/Fill ObstructioNDebris/Fill removed? ❑ Yes ❑ No PUMP Type GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present ❑ Other FORMATION If not known,intlicate estimated fortnation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: � No Annular Space Exits ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ PeAorated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) Grouting Material '�rom _r�� to�..��, ft. yards i�1 tt bags from to ft. yards bags from to ft. yards bags from to ft. yards bags REMARKS,SOURCE OP DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS Other unseated well or boring on property? ❑ Yes � No LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The infortnation contained in this report is true to the best oi my knowledge. Stevens Drillin� b Env. Sezvi�es 86654! Contractor Business Name License or Registrallon No. �f�1�7 Autho�zed Representative Signature Date kichar� Stevens LOCAL COPY 115 6 6 5 Name ol Person Sealing Well or Boring H HE-01434-02 10/95R � WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIG CountyName WELL AND BORING RECORD � � 5 f- Hennepin � Minnesota Statutes Chapter 1031 �-' Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed W�i��E�'�. Ora o 117 �3 3 ,,. y .,, 343 " 6/9/97 �I House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD �, 1$Z�} �O]C Street ❑ CableTool ❑ Driven ❑ Dug � ❑ Auger O�iotary ❑ Jetted Show exact location of well in section grid with"X".� Sketch map of well location. ❑ � Showing property lines, ; { `o� � road�ppdtibuildings. DRILLING FLUID " ,� � ' :� Water ', � � � � I -; -;- -;- -,- USE ❑ Monitoring ❑ Heating/Cooling i i i i � �omestic ❑ Communi PWS -�- --�- -L- -�- i`; ❑ Irrigation � ❑ Industry/Commercial i i i i j ... ❑ Noncommunity PWS ❑ Remedial w i I I e `_....---- ; , ❑ Test Well ❑ Dewatering ❑ -r --t- -r- -r T _y,-t l:'�. . i i i - i +/ZM a t f 1�- "' CASING Ddve Shoe? O�es ❑ No HOLE DIAM. _i i _L_ _i_ � C�X 6 tee l ❑ T hrea d e d O 7;Ne l de d i -i- i i ❑ Plastic ❑ S �1 M�le�� y� `��}� i� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME 6 in.to Z�2 fl. Ibs./ft. � �,ro24 2tt �r11C� �. ki�nke in.to n. ibs.in. 6 �n.to�4 3n. Property owner's mailing address if different than well Ixation address indicated above. in.to ft. Ibs./ft. in.to_tt. ISZU F02C .StrS�t SCREEN OPEN OLE Wayzata, MN 55391-933I Make from �42 n.to 343 h. Type Diam. SIoVGauze Length Set beNveen ft.and ft. FITTINGS: STATI WATER LEVEL / WELL OWNER'S NAME �3 ft. ❑ below ❑ above land surface Date measured 6�1� 7 PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. ft. atter hrs.pumping 2�{� �' g.p.m. WELL HEAD COMPLETION C�Pitless adapter manufacturer Mt�$r51 Model ❑ Casing Protection q1Q2 in.above grade ❑ Abgrade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? �Yes ❑ No GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material [JQJeat cement ❑ Bentonite ❑ Concrete ❑ High Solids Bentonite MATERIAL from�to�Z_R. � ❑ yds. �$ags from to ft. ❑ yds. ❑ bags C 1 a y' y e 11 a w 1 from co n. ❑ yas. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATION clay brOW]1 1 ,4 feet direction type Well disinfected upon completion? ❑ Yes ❑ No clay �aaxs#x�x�xx� r� 4 g PUMP 6 j 12/9 7 ❑ Not installed Date installed �f Manufacturer's name �'Ou�d tav�l & s�nd r@ 6 ` Modelnumber HP �l Volts Length of drop pipe ZL^ff ft. Capaciry S� g.p.m. L'�.d & ravel �re 7 8 PressureTankCapaciry 5,��0 Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ cla re � I O ABANDONED WELLS Dces property have any not in use and not sealed well(s)? ❑ Yes CJ No �� . . - - Cla brown �� 1` VARIANCE Was a variance granted from the MDH for this well? ❑ Yes Ca/IVo sand b cla red 22 15 WELL CONTRACTOR CERTIFICATION * Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4�25. REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best ot my knowledge. S �.S"@@ AttBC�'3eC� 5�1£et �censeeeusnress am rc.or eg. o. t ° ! � � _ � (�r,;��c; �� Authonzed Representative Signature Dafe ' Randy Jo�n�zon d.,� Name o/Onller Date �.�-' � �' � �, �: � � ` � � " HE-01205-05(Rev.1/95)