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Home My WebLink Aboutwell info �_ MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. � CountyName WELL AND BORING RECORD � � �� .�� -. Minnesota Statutes,Chapter 1037 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED ° �� I25 " 12-5-D8 GPS DRILLING METHOD LOCATION: Latitude degrees minutes __ seconds � Longitude degrees minutes seconds �_;Cable Tool �� .Driven I ;Dug [_J Auger !lyFiotary I.,Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � �, ' ` DRIEtING FLUID WELL HYDROFRACTURED? [�Yes o Show exact location of well/boring in section grid ith"X" Sketch map of well/boring location. �� rom ft.To ft. Showing property lines, N r.�— roads,buildings,and direction. USE �omestic ,]Monitorin ' g �_]Heating/Cooling __1___ __�____L__ ___i__ �� .^Noncommuniry PWS U Environ.Bore Hole f�Industry/Commercial � �, -�.Community PWS ❑Irrigation ❑Remedial --'--- --'------`-----'-- � �_��.Elevator ❑Dewatering ❑ W , , , , E T ASIN RIA ve Shoe� ' k�No OLE DIAM. C G MATE L Yes H --�-- --�----�-- ---<-- ,�_ ' `- -- G Dri � I � / _Steel r Threaded ❑Welded 'h M'ie ��r ,.,....� jJ l �plastic r 1 �,/� t � (y CASING � � S � � � Diameter * Weight Specifications ��. �1 Mile—� � in.to 1�� ft ��'" Ibs./ft. �� in.to ''ft. . PROPERTY OWNER'S NAME/COMPANY NAME in.to _ft. IbsJft. �in.t�ft. ��h q�� a�j'j in.to ft. IbsJft. in.ta ft. Property owner's mailing address if drfferent than well location address indicated above. SCREEN OPEN HOLE � $� $� Make � From ft. To ft. Type •��.�t...... ..�t Diam. N �G aICZZAa—�LT--- SIoUGauze Length_ Set between �ft.an FITTINGS�� STATIC WATER L Measured from _�___ft.�. �' elow I,� ��Above land surface Date measured �+�� WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) ft.after 1 hrs.pumping ��g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION �, • �pitless/adapter manufacturer ...�.�� ..��>�--��a��'�RAodel !J Casing Protection '��C72 in.above grade (�At-grade(Environmental Well and Boring ONLY) � GROUTING INFORMATION Well grouted �,14'es [No , Grout materials J Neat cement i�entonite ❑Concrete ❑Other From_�_To__�_ft. _�___ ❑Yds. ��'Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_��_To_��ft.��l�is. ❑Bags MATERIAL From To ft. ❑Yds. ❑Bags NEAREST KNOWN SOURCE OF CONTAMINPT�^N ,/, caly/gravel bro�wn seft t� 15 z� � �r {' � feet _ _. direction �""�"� —��'�}yp (�Well disinfected upon completion? �.'Sles []No ��y„r��.„�-- �y ��y �� j�PUMP �3��$�� $v `_,�� 12S U Not installed Date installed �::"` ��j%� J --� e3i�E3CE � �xlCil # Manufacturer'sname t�..rv�.� .+�..s�"'�+�^ """ Model Number � HP_�Volts + �� Length of drop pipe>�� p��.�G.. fl. Capacity g.p.m. Type:f ubmersible I`,.I LS.Turbine (1 Reciprocating ❑Jet ❑ ABAN ONED WELLS Does properry have any not in use and not sealed well(s)? �]Yes �,a}elQo 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 repor�is true to the best of my knowledge. Use a second sheet,il needed. !� rL ,t 1 T 3� 2 j p �:� REMARKS,ELEVATION,SOURCE OF DATA,etc. R�C,�S• �aCZ� DC11Z1T�j CO�� 1CIC• � CLLViH1OCI QS D�#StOd0�8 W�LI 1?C�II�.tl}�, CQ,• �I1C. If?�� Licensee Business Name Lic.or Reg.No. ., f . f-`'` /..�' /� �� C � e ignatUre _ -- c.--'�-Certified Rep.No. Date 7 6 5 �2 2 �c �c�rre LOCAL CdPY Name of Driller IC 140-0020 HE01205-11(Rev.3/07) � . rw i�vv C i,tr 1Na��' C ' ' , I vu�. y 617 13th Ave So • Hopkins, Minnesota 55343 � (612) 935 - 3556 12/10/2008 Stodola Well Drilling 3841 North Main Sr. Bonifacius MN 55375 938-21 1 1 REPORT OF WATER ANALYSIS Lab #: 5276N Our Laboratory reports these analytical resulrs, derermined on a sample taken by CLIENT on 12/OS/2008 from the following location: Keith Vanden Branden 1465 Long Lake Blvd. Orono,Mn We�L 765522 Coli form Bacreria Absenr Nitrates Nitrogen <1.0 mg/1 Arsenic 9.80 ppb Twin:C'i,f� Water �nic, Inc. t t Bill �� sdale Analyical laboratory ConsultingErtgineer Water Malysis Reagents Boiler Water Chemicals Lab Certification#027A53-119 V�ELL OR BORING LOCATION ' MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 'H ��C��Q County Name WELL AND BORING SEALING RECORD Minn�esoNa Unique Well No. �' �� ?��_—q�p�� ^ Minnesota Statutes,Chapter 103/ or W-series No. +�..i�1lA irii (Leave blank il not known) Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed Oto� 1$ 23 't►1E ''�1'' 1 _C 4 +� , �� GPS Latitude _ degrees__ minutes ____ seconds Depth Before Sealing /U ft. Original Depih_ ft. LOCATION: Longitude ____ degrees_ minutes seconds -- ---�-�— Q IFER(S) STATIC WATER LEVEL � � Nu��ric�al Street. Address orT F�NumDber and;ityo Wel��l or�Borin�535� ingle Aquifer ❑Multiaquifer ,[5 /�y�,� i�no Measured � Estimated Date Measured 1�'� !/"'� ��5 aw�►ab LI�Rt Dl� �W(E�''.U' BORING � � � L�7wvater-Supply Well ❑Monit.Well � Show exact location of well or boring Sketch map of well or boring �p I in section grid with"X." location,showing property ❑Env.Bore Hole ❑Other h. �below ❑above land surface lines,roads,and buildings. N CASING TYPE(S) � --'-----'--- ---`-----'-- � �Steel ❑Plastic [�Tile �]Other "'"' "�'-' '-'`" "''- WELLHEAD COMPLETION �� W ; ; ; : T � __�__ _;__ __�__ __�__ Outside: ❑Well House I�'��At Grade Inside: ❑Basement Offset '�� Pitless Adapter/Unit ❑Buried ❑Well Pit , ; � / _ ❑Buried L �(/ ❑Well Pit S "tNG 1 e i 1 Mile—� � v.�Q.�r ❑Other ❑Other PROPERTY OWtN7ER'S NAME/COMPANY NAME CASING(S) � r Dia�me/yerJ/ � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diflerent than well location address indicated above '7 In.ffom Q to �/ ft. ❑Yes [�o ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to n. [)Yes ❑No []Yes [j No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � i �/7(� Well owner's mailing address if diRerent than property owner's address indicated above SCfeen ffom �� to ` �'" ft. Open Hole ffom to _ ft. OBSTRUCTIONS �Rods/Drop Pipe (�Check Valve(s) ❑Debris ❑Fill L]No Obstruction � Type of Obstructions(Describe)��/�/�� / _�F��_.__4"_ �U�� _ , — GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? I�es PORMATION ❑No Describe If not k wn,indicate estimated formation log from nearby well or boring. PUMP n 0 I TYPe �V� '"` C1�A �emoved _Not Present `J Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: `,,�No Annular Space Exists ]Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed � ti Type of Perfora[or - ❑Other ___ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) � /�/ r � , Grouting Material�� C..'Cl/�/v om � to �� ft.______ yards � bags from to ft. yards bags from to _ ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �,�Yes ,�o How many? �k LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules.Chapter 4725.The information contained in this report �S�rU�:�:S�:�`�e��1e�rilling Co,. Inc. a divi�#ion of don Stodola �Tell Dri2lingCo., Ir�. 1691 .. - --- - ----- -__ ___ __ Licensee Business Name L�cense or Regrstration No. � /�,� /�,2 U� C es ta�ve Signatur � Certilied Rep.No. Date H 275489 �� ' ; LOCAL COPY � Name of Person Sealing Well or Boring - � ----- -- ___ .___i__ , HE-01434-11 IC#140-0423 ' 2/oaR a