HomeMy WebLinkAboutWell Sealing Record�,� - .: _. _ . , f.R,�. . , , .-.._ :.. _ :
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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIt�UEWELL NO.
co��cY rvame WELL AND BORING RECORD ('�
� �� Minnesota Statutes, Chapter 103I �1 �(� �.,i W���
,. Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
� GPSL�� 11Q `� � / / / DRILLING MET OD7 n 1Z�IS�J�F
Latitude degrees minutes seconds
�;' LOCATION: — '_l Cable Tool i riven � .Dug
�. Longitude degrees minutes seconds `�
Auger �Rotary I�Jetted
� House Number,Street Name,City,and Zip Code of Well Location or Fire Number �J
fJY � t7 �CA�IO SS.7S� DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No
Show exact location of well i�section grid with'X". Sketch �a f we!I location. �Ater
- Sh in roperty lines, FROM ft.TO ft.
,�.� oa and buildings USE
� N i j ! `�` '� �Doncosmmuniry PWS 0 Monitoring ❑Heating/Cooling
� . _j____j_____�__ _____ En9ron.B9re Hole O Industry/Commercial
,. j ; ' f ,_,N Irri ation Remedial
., ; ; , , ! r,_ � ❑Community PWS ❑Dewatenn
--'-----'-----`-- ---�-- t ,�,(
, W i i i ; E \ \ ASIN Drive Shoe? ❑Yes �1 No OLE DIAM.
C H
_ __;_____�___ _.�_____;__ I A �� ❑Steel ❑Threaded ❑Welded
�( ,� k Plastic ❑
� � � � � Mile . ..
,h .�
--------------------=- 1 ��
� � � � CASING DIAMETER WEIGHT
� � 5 � � 4�
� _�__in.to 191 ft. 2�lJl IbsJft �in.to�ft.
'�, �1 Mile--� �
q in.to fL _ Ibs./R �in.to��ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft.
�1� M� SCREEN OPEN HOLE
Property owner's mailing address if different than well location address indicated above. Make� FROM tt. TO fl.
15{7l � ? Type "�`����� *� Diam.
� ^t11
���} y� 5��� SIoUGauze •V11J _ Length f + (�t
1'!t� J Set between� ft.and_�ft. FITTINGS .��
STATIC WATER LEVEL
��ft. �below C above land surface Date measured �,��f�
PUMPING LEVEL(below land surface)
WELL OWNER'S NAME/COMPANY NAME
__ft.after�____ hrs.pumping g.p.m.
W LL HEAD COMPLETION
�?��i�. Well owner's mailing address if different than property owners address indicated above. �Pitless adapter manufacturer �it�.tec Model
� Casing Protection ._..____ I�12 in.above grade
� ' ',.J At-grade(Environmental Wells and Boring ONLY)
, � GROUTING INFORMATION :�
�� ,� Well grouted �Yes ['No b�
Grout material �, J Neat cement [J Bentonite . �Concrete�1 High Solids Bentonite
�., from�to_�'ft �__ ❑yds. �ags
. from�__to_��ft. ���!���❑bags
- GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. jJ yds. �; I bags
MATERIAL
'• NEAREST KNOWN SOURCE OF CONTAMINATION
V �'r� feet '' direction -�' y-_--�-''�T"tyFfe
,�. Well disinfected upon completion es ❑No ._���•.+--.. �-'�-3-R.J��--e
�� PUMP
�^� ❑Not installed Date installed 1�'�Z�
Manufacturer's name �rn�tflr
�':,�
" Model number HP ��� Volts ��
,'?:., —
Length of drop pipe ��/ ft. Capacity g.p.m.
� Type:. Submersible ', �LS.Turbine ❑Reciprocating ❑Jet j � '�
ABANDONED WELLS �-�
Does property have any not in use and not sealed well(s) L]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. ]� ,S't,�(�,1�{ �cl� JJ�I1fT� C�- 3lx:s 4I1!-L
,
Licensee Business Name �or Reg.No.
F :"���,� J,,..,-y,' ��
w - - 1-26-05
�� � ' . , .�r : ;;�=
�/1� A ho d`RepresentativeSignature Date
~' -� _ti. ���L
:: / � 411i�t�lC �
� LOCAL COPY 7 ��Q �(� Nameo�Dril/er .
� � v � HE-01205-OB(Rev.5/02)
IC 140-0020
7~w i�vv C i,t� litl a�t��' C ' ' , I�•
y
617 13th Ave So - Hopkins, Minnesota 55343 � (612) 935 - 3556
12/17/2004
Stodola Well Drilling
3841 North Main
St. Bonifacius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab #: 956
Our Laboratory reports these analyiical results, determined on a sample taken
by CLIENT on 12/15/2004 from the following location:
849 Brown Rd. N
Orono,Mn
Well #719800
Coliform Bactevia <1/100 ml
Nirrates Nitrogen <1.0 mg/1
The results of these tests indicate that this well is producing watev thar meets the
standavds for F.H.A., V.A., or conventional loans. This report is an analysis for
coliform and nirrate only and does not include analysis of Lead and other
contaminants. (Unless as speci fied by clientj.
�Twin City Water Clinic, Inc. �
Bi'1.� n Arsdale
�
\��
Lab Certification#027-053-119