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Home My WebLink AboutWell info s.. S MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I � WELL OR BORING LOCATION � WELL AND BORING SEALING RECORD Minnleso a�Unique Well No. � County Name Minnesota Statutes, Chapter 103/ or W-series No. (Leave blank il not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Conshucted � S�W C� -� In �7 _ � GPS Latitude__ __ degrees__ .__ minutes_. _ seconds Depih 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 Single Aquifer ❑Multiaquifer �/�M /�/ 2pV1 P(n[ Jt �� 55356 WELUBORING �vieasured ❑Estimated Date Measured �/��"� �i'/ Water-Supply Well ❑Monit.Well 1 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 ,� lines,roads,and buildi s. �� ; N � ASING TYPE(S) " --'--- --i----"----'- �: Steel ❑Plastic ❑Tle ❑Other � --i--- --�-- ---F-----7-- WELLHEAD COMPLETION � w ; ; ; ; ET � � � � � V,� Outside: ❑Well House U At Grade Inside: ❑Basement Offset --�--- –;--- --�-----*-- � , , , , Mile �Pitless Adapter/Unit � uned , ell Prt �h � g ' ]W ------------ ---------=- 1 , - ��Buried S ❑Weil Pit � ❑Other �-1 Mile—� - ❑Other PROPERTY OWNER'S NAME/COMPAN ME CASING(S) Diame e�� /) � Depth / � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above � in.frOm `� to � r ft. ❑Yes �No ❑Ye5 ❑No ❑Unknown _in.from to ft. ❑Yes ❑No (]Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes [�No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r � Well owner's mailing address if diflerent than property owner's address indicated above SCreen f�om r�' to � � Jtt. Open Hole ffom to ft. OBSTRUCTIONS ❑Rods/Drop Pipe [�Check Valve(s) �.,_j Debris �Fill �No Obstruction _ Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO �bstructions removed? ❑Yes ��No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. � � Type _ �;�Removed [�lot Present ❑Other - METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �o Annular Space Exists �]Annular Space Grouted with Tremie Pipe �Casing Perforation/Removal in.from to ft. [j Perforated ❑Removed - in.from to______ ft. ❑Perforated ❑Removed � Type ot Perforator__ _____ _ ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � �.+r I � Grouting Material/U'�� C�J�'L U�from d to� ft. yards�� bags from to __ ft. yards bags from ro _ ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICUITIES 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. � RE.S �Iell Arilling Co., Icrc. a division of ;' ----- -A��todo].a_ �2r�lling-Co��_Icic�_ 1F�1 __. _ _ Licensee Business Name License or Registration No. _ _ �-,�3 a � en ative � u Certified Rep.No. Date � -- ----—� --�- — � '� ' H 275530 �-��-- ` LUG��.L COPY Name of Person Sealing Well or Boring � � --- -- _ _ HE-01434-11 ICn 140-0423 � 2/oea FROhI : FAX N0. : Feb. 16 2�99 12: 12PM F� c ' Tl�vi�v C i.�t"y yt1�"e.�' G " � , .�� 61.7 ].3th Ave So • Ho kins, Minnesota 55�43 . 612 935 - 3556 Q2/16/2009 Stodola Wel! Dri!ling 384) Norrh Main St. 6oni facius MN 55375 938-21 J 1 ��OR'�'��'WA'�'ER ANALYSIS L�b #: 44SN Dur�aborarory re�orts these c�ndl ytital results, determined on a sampie tcrk�r� by CUFN7"on Qz/12/2009 from the follawing locatian: Daniel Kluth 2801 Fox St. Orono,Mn W eZL T 7'0002 Coliform Bacteria Absent Nitrates Niiroye� <I.0 mg/! Arsenic �Z.O ppb Twin ater Clinic, Inc_ B�'V r dale Annlyicu)laburrtory CoosulcinR BnFtineer W'atcr iU�alyeis F2cagcn[s Boilcr Wat¢i c;hi;mic;Hlx 1.Kh Certificntion�027-0>3-i I� � MINNESOTA UN/QUE WELL WELL OP,BORING LOCATION . MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING RECORD � � O G� � Minnesota Statutes,Chapter 1037 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED S�E NE��SW �� 124 " 2-22-49 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ Longitude degrees __ minutes seconds �_�Cable Tool Driven �, i Dug i Auger 17�Rotary _-��,Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number �1 � . DRILLING FLUID WELL HYDROFRACTURED? ❑Yes i�Fla Show exact location of well/boring in section grid with"X" Sketch map of well/borin lo�6n. �C� From fL To � ft. ' �' Showing prop r es, � �-"' ` ' � u ion. USE N , ,,,, Domestic �Monitoring ��Heating/Cooling __1_____J___ ___L_. ___L_ J � ��,�� `` oncommunity PWS �]Environ. ore Hole [j Industry/Commercial ' 1 ' ; ""� ��"^� } f� ` �-�,Eevatorniry PWS r]DewaterBg �Remedial . --'-----,------`-----`- � Lj � �� ,,. w ; , i ; E� 1�„^.� �'� ASIN Drive Shoe. L�Yes - No OLE DIAM. ' MATERIAL H C G --�-----�------�-----:-- I]Steel �:�_,,Threaded [j Welded , � � , 'f_Mlle � StiC ' _ la r --,-----.-----�-----:- 1 - 1 ; ' ' � CASING g �� Diameter Wei ht Specifications �` 4 116 �.9 �st�r S 54 F-i M�ie� -.� in.to___ ft. _Ibs./ft. in.to7��ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. _ �in.to ft. �3,��J� �Z�j�h in.to ft. Ibs./ft. in.to ft. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. - � � 8� Make � From ft. To ft. TyPe S�B�e�� Diam._ SIoUGauze •�1�) Length � 'f" � Set between_�"L�ft.and__��ft. FITfIN � � S�fATIC WATER LEVEL Measured(rom tt. � elow �r 1 Above land surface Date measured WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ft.after hrs.pumping g.p.m. Well/boring owner's mailing address if different than properry owner's address indicated above. WELLHEAD COMPLETION ;� q.. �Pitless/adapter manufacturer - 3�'� , . �• ��+�-��-,lModel �Casing Protection _ h.f12 in.above grade �l At-grade(Environmental Well and Boring ONLY) 7^ GROUTING INFORMATION Well grouted �;Yes (.]No Grout materials [�Neat cement �Bentonite []Concrete ❑Other Fom__�To__�.ft. �_ _ �_��,Yds. '�Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From__��To�_��_ft.��u��s. ❑8ags MATERIAL From To ft. �]Yds. ❑Bags NEAREST KNOWN SOURCE OF CONTAMINATION C�� ft Q �� °,.,,%� feet `-R� direction r.... .: ::.:a�-:>�`,�iy,pe Well disinfected upon completion? r es r-��No ;.'4�,_ ,� C18Y gL"Sy SOft 1C� �O pUMP ; f �e�l �r�V ��t �O ��_��Not installed Date installed � � _r .) � � � Manufacturer's name - clay ��}1 �f� (�O 1 1 A Model Number ' HP ��; olts 1�LJ Length of drop pipe tt. Capacity g.p.m. �Llkl 'br� �l t l�l/ 1 GY Type:� Submersible r,_�LS.Turbine j]Reciprocating ,J Jet ❑ ABA DONED WELLS - Does property have any not in use and not sealed well(s)? �J Yes �� o VARIANCE Was a variance granted from the MDH for this well? � '�.Yes ' -o 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. R�D�*�• rsG�� uL1�I� 4V�� InC• a dfvi.sion of DO[�.Stt�l�_�Tell Drillit� CA., IilC. 1591 Licensee Business Name Lic.or Reg.No. �-- ' � / 1/ ,, '. �. � .. .�! .�� -� / r e Representative Signata2` Certified Rep.No. Date 770002 `�� LOCAL COPY Name of ori��er — HE-01205-11(Rev.3/07)