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Home My WebLink Aboutwell info wELL oR BORING LOCnnON MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„' � County Name WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. �� n Minnesota Statutes,Chapter f031 or W-series No. ��ve oienk a rwi kno»n) Toxmship Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed tTrem� 117 2 Ob 4 2 �,. �,. � F � . GPS Latitude degrees minutes seconds LOCATION: Depth Before Sealing � ft. Original Depth ft. Longdude degrees minutes seconds p IFER(S) STATIC WATER LEVEI. Numerical Sheet Address or Fire Number and City of Well or Boring Location Single Aqu'rfer ❑Multiaqu'rfer WELUBORING �Measured ❑Estimated Water Suppty Well ❑Monit.Well - Show exact location of well or boring Sketch map of well or boring in seclion grid with"X" location,showing property ❑Env.Bore Hole ❑Other ft. ❑below ❑above land surface N lines,roads,and buildings. CASING TYPE(S) - - - - - -- - -- �__�_� __.._.,—. - `�Steel ❑Plastic ❑Tile ❑O[her n W --�- -i-- -i-- --;— E - WELLHEADCOMPLE710N � � � �,! � Y � � � Outside: ❑Well House Inside: �asement Offset -�- -;-- --�— _ � � � � �� t .lQ_�� ❑Pitless Adapter/Unit ❑Well Pit --`- -i-- -i-- --i-- I � ❑Well Pft ❑Buried s �, �� y �---i^w—+� , _r;�,,,., ` .?r� ❑s��ed t PROPERTY O�*WL�N�ER'S NAME/tCTO..MPANY NAME CASING(S) � ' .711a� vfn�� Di te�� Deptli � Set in oversize hole? Annular space initially grouted? � Properry owner's mailing address'rf diHerent than well location address indicated above � in.from�to�ft. ❑Yes �lo ❑Yes ❑No ❑Unknown 9� 88 ��OV� In.ffOm to ft. ❑Yes ❑No ❑Yes ❑Na ❑Unknown in.ffom to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown - WELLOWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE � C , Well ownei's mailing address if diHerent than property owner's address indicated above Screen from�t0�ft. Open Hole from t0 ft. OBSTRUCTIONS ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill f�No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑YeS ❑ NO DeSCflbe FORMATION If not known,indicate estimated formation log from nearby well or boring PUMP •'� �T TYPe ��'�' ❑ Removed ot Present ❑Other : .AETHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: pr No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing PerforatioNRemoval /� in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) ,+i � � Grouting Matenal��'L�� ///�''��from�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 No How many? 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 of my knowledge. Tbn Stodola t�ell Drillin;� Co., Inc. Z7I72 Contractor Business Name License or Registration No. ''!i ..i J .�-t _ /'�.-'�°'� .�'`�/ J,,,.-.� , &pfe�eir(ative Signature Date � ��. ,.. _ . �� - �"�< <�::.��, �..J LOCAL COPY H ��$� Name o/Person Sealing Well or Bonng ,�� x.,�, _ �;., ,� . . . .. . , , >. .. ..__. � , 1 . � . _ , .... . , , ,„. _, � . . ... , �. _ - �...:� „ . ,.. ._: ... - WEL�LUCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUEWELL NO. �� County Name WELL AND BORING RECORD {,, �p� Minnesota Statutes, Chapter f037 ^r �� Township Name Township No. Range No. Section No. Frection WELL DEPTH(completed) Date Work Completed ' �1D 117 Z� � y, y i 1�0 n �d"'�"'(� GPS DRILLING METHOD ' LOCATION: Latitude degrees minutes seconds _�� . Longitude degrees minutes seconds ��Cable Tool �'Driven ��]Dug �Auger �Rotary ��Jetted � House Number,Street Name,City,and Zip Code of Well Location or Fire Number -� - � �;"�� " �!"�� 5� DRILLING FLUl�trl}e WELL HYDROFRACTURED? ❑Yes I o � Show exact location of well in section grid with"X". Sketch map of well location. «�16 Showing properry lines, FROM ft TO ft. N roads and buildings USE . [�Monitoring ��'��Heating/Cooling _ ___ _ _ _ `� �Domestic ❑Environ.Bore Hole �J Industry/Commercial .� : :_. : i J i i �� LI Noncommuniry PWS '-�Dewaterin , Remedial : ��Irrigation � � Community PWS �_; g .. 'i_. -�` CASING HOLE DIAM. 2 w , , e T -�� ive Shoe? Yes j�No � � • Dr '. ,--- - ; _�-- -;-- I `�-*� f�Steel � j Th�eaded �,Welded ' 'h Mile lastiC '� ] -- --,--- --.-- � -�-- 1 =� . CASING DIAMETER WEIGHT S ' ' 1 �. , � `1 in.to �� ft, �� . IbsJfL �in.to r� i 1 Mile� — - �. in.to__ _____ft. Ibs./fL �in.to �� PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.�o ft. `xiAL�}T� FfBt� SCREEf�.,f_._�,� OPEN HOLE �� Property owner's mailing address if different than well location address indicated abova �� Make� FROM M_ft. TO ft. � � aW�' TYPe— �� -_—__ Diam. -_ — SIoVGauze_ �y'+� Length��f� Set between�ft.and�_ ft. FITTINGS�__�Y � STATI��ATER LEVEL ��5 ft. elow [1 above land surface Date measured PUMPING LEVEL(below land surface) ' WELL OWNER'S NAME/COMPANY NAME 1� ft.after_ 2 hrs.pumping��__ g p m � WELL HEAD COMPLETION � �. Well owner's mailing address if different than p�operty owners address indicated above. �itless adapter manufacturer -� � �-��"�>—+�-��"�fplodel �Casing Protection �12 in.above grade �At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATION - Well grouted �es ;J No Grout material ❑Neat cement ❑Bentonite r;Concrete,�High Solids Bentonite � from � to � ft. 3 �-��yds �6ags � from�to�ft. Q�tt�ra3 �j�CJ. �' bags GEOLOGICAL MATERIALS COLOR H MADTERSA OF FROM TO from to ft _,yds. ��—�.bags , NEAREST KNOWN SOURCE OF CONTAMINATION t[971OA.L1 �1,�� '� 0 3 "'. `.. _ feet ...-'�'�''_3 direction �.�✓--)^'�' 'l'al+''-d`.1�` v "r"" Well disinfected upon completion es � 'No -,_\,ti,.,_, �,,,yl._��. _y� ,��w �� PUMP � . C� L�7V1LS .Not ins�alled Date installed �'J T�'"�J `-�-� �►�a �gt 9P1 420 Manufacturer's name_ ��--._.•�`--��-+.w-- �-:"'�°s "� k�J L Model number HP J��Volts �`7 � b� �1 G i� 1�Length of drop pipe /`l� ft. Capacity g.p.m. Type:' .;Submersible j �L.S.Turbine ❑Reciprocating �J Jet ❑ � ABANDONED WELLS 3 Does property have any not in use and not sealed well(s) �_]Yes �No VARIANCE Was a variance granted from the MDH for this well? ❑Yes ' No TNu 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. � SEodola We.I.2 Dcil�ing Co�• i� 4�!� Licensee Business Name Lic.or Reg.No. _. . // /�' �.,' th e Representative Signa�ture Date .., � 1 R)f)� LOCAL COPY �� ,�[; � NameofDriller ej� HE-07205-08(Rev.5/02) IC 140-0020 r . - rw�,�. c�y w�� c � � , .r�,�. 617 13th Ave So � Hopkins, Minnesota 55343 • (612) 935 - 3556 10/04/2005 Stodola Well Drilling 3841 North Main Si. Bonifacius MN 55375 938-21 i J REPORT OF WATER ANALYSIS Lab #: 596BN Our Laboratory reports these analytica/results, determined on a sample taken by CLIENT on 10/03/2005 from the following location: Doug Watson 680 N. Arm Dr. Orono,Mn Well#726445 Coliform 8acieria <1/100 m! Nitrates Nitrogen <1.0 mg/1 The results of these tesis indicate that this wel!is producing water ihat meets the standards for F.H.A., V.A., or convenrional loans. This report is an analysis for coliform and nitrate only and does not include analysis of Lead and oiher coniaminants. (Unless as specified by client). � 'n City Water Clink, lnc. Blll Arsdale Lab Certification N 027-053-I 19