HomeMy WebLinkAboutwell info ��7ELL'LUC?�,TION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
�o��ty Name WELL RECORD ��6 4 � 6
I3es�ne�i.n
Minnesota Statutes Chapter 7031
Township Name Townrysh-ipp No. � Range No. Section(No. Fraction WELL DEPTH(completed) Date Work Cotmplete-d7 (_
11.L�G 1 1 ! L'.�J �Lt � ��.� ry. � }'—� I'�7�
/. /. /.
Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
'��J� �5��[7e �•'�j� Crr���� �. ❑ CableTool ❑ Driven ❑ Dug
� ❑ Auger ��Aotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
N roads and buildings. DRILLING FLUID
I � _i _i_ �P.I3i.t)I�2���G
--r--7- i i
i � � i tL .USE ❑ Heating/Cooling
__�_ ___ �_ �_ ��, �Domestic ❑ Monitoring ❑ �ndustry/Commercial
yy i � i , E X ❑ Irrigation ❑ Public ❑ Remedial
_1_ _1_ __ � T ❑ Test Well ❑ Dewatering �
I � �"
�'^"� � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
' 1'��- �- — —�' �` �Steel ❑ Threaded ❑ Welded
� �m_'�_� j ❑ PlaStiC ❑
\
� CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME �x� �� �ej �_in.to ��� ft. Ibs./ft. / y in.to � '-ft.
in.to ft. Ibs./ft. '��in.to��i'_-+-ft.
Mailing address if different than property address indicated above. in.to ft. Ibs./ft. in.to ft.
�CiV .�-OLZ4-ti BTt.3c�CCISN�.V SCREEN��_ OPENHOLE
�ay�"��� [�. �rj,j��{ Make� �� t�7 from tt.to ft.
Type i Diam. %N
SIoVGauze �� Length
Set between 1�$ ft.and Z J% ft. FITTINGS:
HARDNESSOF STATICw���LEVEL 11-1 �-�9"
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO ft.�below ❑ above�and surface Date measured
C,��t' � �.,,�„,� ��! �C� PUMPING LEVEL(below land surface)
i .�aiiu v
ft. after hrs.pumping g.p.m.
�I'K� �6�� � 1� C3KPi I ss ad ptOer^manuflaOc urer ��"t���� Myodel
❑ Casing Protection O"12 in,above grade
GROUTING INFORMATION
Well grouted? �'Yes ❑ No
Grout Material ❑ Neat cement �Bentonite
from to ' tt. � ❑ yds. � bags
from to tt. ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
NEAREST�O�NN SOURCE OF CONTAMINATIO� C�p�/C
S feet �t J V v � � direction �"` -�' type
Well disinfected upon completion? LI'Yes ❑ No l�p��
PUMP �..,
3 G-"I�^J J
❑ Not installed Date installed
Manufacturer's name C�
Model number HP__��olxs a'.J�.1
Length of drop pipe ft. Capacity. S g.p.m.
Pressure Tank Capacity �-�I2 �V Z�Z
Type: �{Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Z>
Does property have any not in use and not sealed well(s)? ❑ Yes �'No
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.
rX::� E��t`�Le'; 6�'�:.�, U�'tI:[:,#:,II�;iC� i.'::�. , :r?+iC:. .:'r'1'i�
Use a second sheet,if needed
REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee eusiness Name Lic.or Reg.No.
�:f���-��" -..�-�.�,�'r 11-17-93 _
Authonzed Representative Signature Date
I'.P. �zen 11-1i-93
Name ol Driller Date
�
LOCAL COPY � ��q, 2 6 HE-01205-04(Rev.5/92)
� Minnesota Well and Boring 2 8 8 5 9
WELL OR� ��+iiNG�oCaTioN �_.,. MINNESOTA DEPARTMENT OF HEALTH Sealing No. H
�o�_��Y N�;,� WELL AND BORING SEALING RECORD M���esota un�q�e No.
iit?T�1k='�%lf: Minnesota Statutes.Chapter i031 or W-series No.
�Leave blank i�noi known)
Township Narne Township No. Range No. Section PJo. Fraction(sm. �Ig.) Date Sealed Approximate Date Well
i.;�,�Yf',. .�,�; �i ,�`, ._; or Boring Consiructed
14 l4 �4 �'�1 'f v
Num1encal St�re7,e-t,�A,-ddress or Fre Number and City of Well ors.B�.o.,ring Location
1 i.{.;i a_�cv.E�1t��T� .�c�n� 1�(l�=i� a-�y. Depth Before Seahng ft. Original Depth -� ft
Show exact location of well or bonng Sketch map of well or boring Stat�c Water Level ❑Accurate
in section grid with��X��. location.showing property lines.
� roads.and buildings. �Approximate
N t.;
� � � � i
� �� ��� ��� �� � �Single Aquifer ❑Mul�iaquiter � � ft
I . � below above land surlace
-�- -�- -1- -�' � � ' \ � CASING TYPE
W i i i i E ` � .
� � � � � '�
-r -�- -r- -i- .
i � � � � � �,Steel ❑Plastic ❑Tile ❑Other
o mile
_I I I 1_ � . ... .+ ` .!'...
t
1 I I I J
� � .'� .�u.,
S Screen from to ' fl. Open Hole(rom to ft.
�1 mile E
� � f - OBSTRUCTION/DEBRIS/FILL
❑Obstrudion ❑Debris ❑Fill
PROPERTY OWNER'S NAME
€3x'i� F:r�rr Fi���7
Type of debris/obsiruction
Mailing Address if different than property address indicated above.
Obsiruction/Debris/Fill removed? ❑Yes ❑No
�t1E` :r. �:SI�+ zrt';4tia.3�y PUMP
i�'y2.'�+-..��, :'fi. _.. �y'�
�Removed ❑Not Present ❑ Other
CASING
GEOLOGICAL MA7ERIAL COLOR HARDNESS OF FROM TO
FORMATION
Diameter Depih Set in oversize hole7 Annular space initially grouted?
If no�known,indicale estimated forma�ion log from nearby well or boring.
_ � )
i ,,' `� in.from to �"�l ft. ❑Yes �,No ❑Yes ❑No ❑Unknown
�� `. =�
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
❑No Annular Space Exisis
❑Annular space grouted wi�h tremie pipe
❑Casing Perforation/Removal
in.from to fl. ❑Perfora�ed ❑Removed
in.irom to fL ❑Perforated ❑Removed
Type of perforator
❑Other
GROUTING MATERIAL
i
Grouting material �� i-�� ���from to � ; ft. yards � bags
from to ft. yards bags
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING
from to f� yards bags
from to k yards bags
UNSEALED WELLS AND BORINGS
Other unsealed well or boring on property9 ❑Yes �No
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in ihis report is
irue to the best of my knowledge.
i�l7n ��r;LL'.In€� ►e�:L,+_: Iih�:ut�Tl�iC.; C;t:., :li�(�. �:t3i:_
Contractor Business Name License or Registration No.
_.—"'.-. ; � i �—�-93
�-�„
ufhonzed Representa�ive Signature Date
�-.rLf_.C'j.�
��:A���PY H 2 8 8 5 9 ���,��, _ . _.�.
Name of Person Sealrng Well or onng
HE-01434�01
>� •
2'�tnn City �Vater Clinic, Inc.
61713th Ave So • Hopkins, Minnesota 55343 • (612) 935- 3556
11/20/1993
Stodola Well Drilling
1 5306 Hwy 7
Minnetonka MN 55345
938-21 1 1
REPORT OF WATFR ANALYSLS
Lab#: 21505
Our Laboratory reports these analytical resuits, determined on a sample taken
by YOU on 1 1/18/1993 from the following location:
Bruce Bren Homes
1135 Heritage Lane
Orono,Mn
il niqu.P.� 526426
Coliform Bacteria <1/100 m)
Nitrates Nitrogen <1.0 mg/I
The results of these tests indicate that this well is producing water that meets the
standards for F.H.A., V.A., or conventional loans.
�
� �,
`Tv�i .; ter Clinic, Inc.
� \
Bill V �� rs ��
Brian B ir
Analyial laboratory Conultu�g Fig�neer
Water Analyou ReageatP Boilor Wator Chomicalr