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Home My WebLink Aboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH M�N AEND BORINI�G NO. ELL co,,,,tYName � WELL AND BORING RECORD �, �, �?i� Minnesota Statutes,Chapter 1037 ��5 Y,,,� � ,�,,� � Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED t3rcxio 117 23 �7 �,� ,, ,, 228 �� 5�-8-07 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 ,I] 741 tR7�h AL�I L7L �=L�0 �SJ�J'F DRILLING FLUID s WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. """"t�it� Showing property lines, From ft.To ft. roads,buildings,and direction. USE N �Domestic U Monitoring ❑Heating/Cooling � � � � � _ � �!�(�/ ❑Noncommunity PWS ❑Environ.Bore Hole ❑IndustrylCommercial �\� � --'----'--- ---`-- --'- � � ❑Community PWS ❑Irrigation �_]Remedial "' � � � ; ,� /� � ❑Elevator ❑Dewatering [] —'---—'--- --`-- ---`-- �`-1,/ �: - W , , , , E p( 't CASING MATERIAL Drive Shoe? ❑Yes �'No HOLE DIAM. --,-----;-- --�-- ---:-- T ? � ; ; , , Miie e hreaded elded �� .� St el ❑T W , , , , � Plastic ❑ " '' --�--- --�-- --�-- ---%- � CASING S � `�, Diameter Weight Specifications �i Miie� ; �in.to�_ft. _�,.��Ibs./ft. ��*t!� �in.to�ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./R ___ .�in.to�ft. �+� �r�� in.to ft. Ibs./ft. in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE � � �� Make .�A}1l49Afl From ft. To ft. Type g��s $t'�_Diam.�� SIoUGauze n1 n Length • Set between ft.and ft. FITTINGS STATIC WAT EL - p Measured from C75 ft. Below ❑Above land surface Date measured ��T WELL OWNER'S NAME/COMPANY NAME PUM�f�Cy,�EVEL(below land surface) �.� �� 1 Z� ft.after hrs.pumping g.p.m. Well/boring owner's mailing address if diNerent than property owner's address indicated above. WELLHEAD COMPLETION � �Pitless/adapter manufacturer � � � '"''`�ifAodel ❑Casing Protection �12 in.above grade � ❑At-grade(Environmental Well and Boring ONLY) GROUTING INFORMATION Well grouted �Yes ❑No Grout materials ❑Neat cement ❑Bentonite ❑Concrete ❑Other From�To__,25L R � ❑Yds. ,�Bags HARDNESS OF From 7�To��,tE1�8� ��Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO From 215 To��$_ft. �_ _ � J Yds. �Bags NEAREST KNOWN SOURCE OF CONTAMINATION r �' � �-'�$y yellaw gQlt � � _ �� __feet �� direction ""'� ��ype p ��' Well disinfected upon completion? Yes ❑No •�'.�.�...., Cl� g� �lt 16 UMP . . ) `'s c ^ ❑Not installed Date installed -� � ` j� � �� ""' `� Manufacturer's name ! � �--�� -'- Model Number HP�Volts "� ✓��J clay bro�m soft 210 21 � - � � Length of drop pipe ` " `-�• ft. Capacity g.p.m. ��=,a�1 1.r�n �C� ^t� �� Type:�Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ 1 �r � GI ABANDONED WELLS 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 TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Ruies,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. � REMARKS,ELEVATION,SOURCE OF DATA,etc. Dan Stodola Well Dcillin� Ca., Inc. I691 Licensee Business Name Lic.or Reg.No. - �'. �� '�� ReprEsentative �� ure Certified Rep.No. Date t�ick t�ooce LOCAL COPY 7 5 �6 5 Q. — — Name of Driller IC 140-0020 HE-01205-70(Rev.6/06) i. rw�. c�y w�� c � � � r� 617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556 OS/10/2007 Stodola Well Drilling 3841 North Main ' St. Bonifacius MN 55375 938-21 1 1 REPORT OF WATER ANALYSIS Lab#: 342BN Our Laboratory reports these analytical results, determined on a sample taken by CLIENT on 08/OS/2007 from the following location: Tomas Barrett 941 North Arm Dr. Orono,MN Well 750654 Coliform Bacteria Absent 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. This report is an analysis for coliform and nitrate only and does not include analysis of Lead and other contaminants. (Unless as specified by client). Twin Cir Water Clinic, Inc. f . eil�1% dale �' Lab Cedification#027-053-119 MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 2 617 3 2 ` WELL OR BORING LOCATION Sealing No. H County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. .. � Minnesota Statutes, Chanter 103/ or W-series No. �p�� . ~ (Leave blank if not known) Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Consiructed OL'�Q 117 �3 �7 Z��t�' L j�! G�/ i GPS Latitude __�� degrees minutes seconds Depth Before Sealing� ft. Originai Depth ft. LOCATION: Longitude degrees_ minutes _ seconds A �FER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Loca�ion . Single Aquifer ❑Multiaquifer �� A�� . WELL/BORING .Measured IJ Estimated Date Measure �� Water-Supply Well ❑Monit.Well � Show exact Iocation of well or boring Sketch map of well or boring I 1 Env.Bore Hole Other �fL �elow above land surface in section grid with'X" location,showing property --- ❑ ❑ N f� �in�es,r�ads/and,, �Idings. CASINGTYPE(S) fi' J \y �Steel �_�,Plastic ❑Tile ❑Other_ _ '` I I ; I • �� ' ' --'------�-- ---�-----'-- '� WELLHEAD COMPLETION �� . W ; ; ; : ET � __;____I__ __�__ ___:__ Outside: ]Well House ❑At Grade Inside: ❑Basement Offset � ° , , , , Mile itless A p r/Und ❑Buried ��Well Pit ,� �� P� da te ' ------ ------ ---�-- ---:- 1 ❑Buried + 5 ❑Well Pit f]Other ___ �i M�ie� u Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) � Diarr�te�r� �/ Dep A Set in oversize hole? Annular sp2ce initially grouted? Property owners mailing a ress i tlitlerent than well iocation address indicated above � � -r in.trom to�ft. ❑Yes �No ❑Yes ❑No ❑Unknown � in.from to ft. []Yes �'i No ❑Yes ❑No ❑Unknown in.from_ to ft. [�Yes ❑No ❑Yes ❑No �..�Unknown �i- WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE f {� � �� Well owner's mailing address if diRerent than property owrer's address indicated above SCreen from___�to C✓� ft. Open Hole ffom to_ ____._ft. OBSTRUCTIONS '� ��Rods/Drop Pipe ❑Check Valve(s) [_]Debris r]Fill �No Obstruction a g Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION — PUMP If not known,indicate estimated formation log from nearby well or boring. � TyPe------ �-� �-'""-�-� '--^� �J� ❑Removed I�Vot Present ❑Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �.No Annular Space Exists i]Annular Space Grouted with Tremie Pipe !]Casing Perforation/Removal in.from to ____ft. ❑Perforated ❑Removed r, _ .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 y/{' y'rl� Grouting Materia��=/"�� '� from V to �/�ft._ __ yards C.� 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 information contained in this report is true to the best of my knowledge. DOA SC0C1018 W�*II DCIZZ�t1�C0.� ZLiC. ],_(j91------ Contraclor Business Name /'� License or Registration No. � � �t, ., ��" _,,,,,: {j � (. er� ep`resentative Signature � � Certified Rep.No. Date { � /,_,.... �� LOCAL COPY H Z 617 3 Z ` { � - r� r� Name of Person Sealing Well or Boring HE-01434-09 IC#140-0423 ..� siosa