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wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H
County Name
WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No.
, or W-series No.
He r►n e i n Minnesota Statutes,Chapter 1031 ������k��a��
Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constnicted
�
orot�o 217 23 lU 3i�- �98'' �
.
GPS �etitude degrees minutes seconds 24 �
LOCATION: Depth Before Sealing ft. Original Depth (t
Longitude degrees minutes seconds ppUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer �/
WEI UBORING Id7�7easured ❑Estimated
��� �Water Supply Well ❑MoniL Well �
. Show exact location of well or boring Sketch map of well or boring
in section grid with"X" location,showing pr rty ❑Env.Bore Hole ❑Other �� ft. �below ❑above land surface
N �J�J�g 1�'Tin�,�ds.an 9S� CASING TYPE(S)
}
� �Steel ❑Plastic ❑Tile ❑Other
W --�- - - �-- —i— E WELLHEAD COMPLETION
� � � �
� Outside: ❑Well House Inside: Basement Offset
�
__f_ __ _ _1__ _j__
1�� ❑Pitless AdaptedUnit ❑Well Pit
--�- -f- -i-- --�— I
1 ❑Well Pit ❑Buried
- �!�—rm�s-�. ,/ Buried
� fI :`±''��,,�r.. �'..:.z �� � ���'.;J j=G�G'1.JI��+�%CCI
� PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
. Diameter �Depth � Set in oversize hole? Annular space inifialty grouted?
� Property owner s m� ng ad ress i � eren an wel dd cated above � / ��
j _�_ in.ffOm�_ t0��ft. ❑Yes 'J�No ❑Yes ❑No ❑Unknown
1409 S. 7tin St. 952-935 55'5$
�0�liLillS/ �N rJr3343 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
j' in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknawn
' WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE
�7'1 / f
we��owner's mailing address'rf diHerent than property owners address indicated above SCfeen ffom�t`�to��ft. Open HoIB frOrit to ft.
� OBSTRUCTIONS
`�Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction
Type of Obstructions(Describe)�,�J��,/�„{�= �L��li .r�
- GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? @S ❑ NO DBSCfIbe
FORMATION
If not known,indicate estimated formafion log irom nearby well or boring PUMP
Type
�"''' ' r ��� Removed ❑ Not Pres nt ❑Other
<
�i � METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
�fJo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
/ '
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 bentonRe=50 Ibs.)
r� � �
Grouting Material��(i r�✓'✓�r'f=.,Yf.c. ��om�_to��ft. yards _� bags
from to ft. yards bags
irom to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFlCULTIES IN SEALING pther unsealed and unused well or boring on property? ❑ Yes o 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.
Contractor usiness ame L� nse s tion No.
__ � ,�� - - i ;1!�
A �'eAR resentative Signa re ""� Date �
,�,'� __. =:
\ � ��
LOCAL COPY H �914 3 �{-
.�... ✓r �,..a��.�.
Name ol Person Sealing Well or Boring . �
" � � .
� MINNESOTA UNIQUE WELL
WELL/BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING N�.
CountyName WELL AND BORING RECORD �7 3 915 8
� i� Minnesota Statutes,Chapter f031
Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
oto�o i�� z3 �a �,, ,,, �,a z�a � �—Za-�
GPS DRILLING METHOD
LOCATION: Latitude degrees minutes__ seconds . _ _
��. �.Cable Tool �Driven -_'��Dug
Longitude__ degrees minutes seconds
flAuger �otary _1Jetted
House Number,Street Name,City,and Zip Code of Well Location or Fire Number � � -
G10V 1'+a)LCit �IC LL QL�O 5539 DRILLING FLUID . �L HYDROFRACTUREq? ❑Yes f o
� Show exact location of welUboring in section grid with"X." Ske h map of well location. ��er �F-r�
i From ft..To ft.
howing property lines,
N �� roads,buildings, USE �_ omestic I]Monitoring f-'.Heating/Cooling
`. � � � � �y and direction. C��Noncommunity PWS 1=�Environ.Bore Hole �.J Industry/Commercial
� � -� ` >J� ❑Community PWS .'Irrigation �� Remedial �
� ; � ; ; '�Elevator _=Dewatering I I.
�' ' ' ' � � CASING MATERIAL Drive Shoe? '. I Yes _ No HOLE DIAM.
` W � � � E T � I hreaded ❑Welded
`, --�--- --'--- -�-- --'--
} _
Steel T
� � �lastic i I
�� --�--- --�--- --�-- ---�-- Mile
'/z
� � CASING
, S � �
Diameter Weight Specifications
�1 Mile—�{ / , �''�, 4 in.to� R. L_�V_�Ibs./ft. �_ �__in.to_�ft.
/�✓:r��,,..�.�.-.�. . =ii_„ .._�.,. )._3.- . in.to. .._._--n' ---Ibs./ft. — �in.to��ft. ,�
. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. �bsJft. in.to ft.
------ �--___. .
��� ��Q Q(� SCREEN OPEN HOLE
Property owner's mailing add�ess if different than well location address indicated above. Make �� From ft To ft.
>
�`!V7 7t11 Ot S TYPe _ _...Sts►inless �t�--- Diam. _. • >
� SIoUGauze�yy�._-- __- Leng�h �r 'F �...- _--- �.
�plcins, P�T 55343 � ,�
Set between R.and ft. FITTINGS
STATIC WATER LEVEL`/ q
_ �_ ft..�8elow ���. .Above land surface Date measured/`27�
PUMPWG LEVEL(below land surfaqce) � L
WEWBORING OWNER'S NAME/COMPANY NAME ���__ ft.after 4 hrs.pumping �fJ g.p.m.
i
' W LL HEAD COMPLETION � �� #- -�}�
Well/boring owner's mailing address if different than property owner's address indicated above. . itless Adapter Manufacturer LT3'4vJy.i-�.J�-�"�3..,,M/odel
� �.Casing Protection ._^`12 in.above grade
� .At-grade(Environmental Well and Boring ONLY)
GROUTING INFORMATION�(
Well grouted? /`\Yes f.�No �/
Grout materials _�__Neal cement X"t3entonite � �.Concrete '��. I Other
From____0 To �__ft. � _'�:Yds. �Bags
From�To?22 _ft.E1$�tlt f1� �Y�� �. �Bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From To ft. i'�.Yds. I I Bags
MATERIAL
NEAREST KNOWN SOURCE OF CONTAMINATION
C7� L� �rt /�► ��-�� feet C-�' diredion_��~"�. ��--u.N-���-''1'�e
ltl U L « Well disinfected upon completion? f�Yes I I No ��
� 1 �C PUMP
U i �.'��Not installed Date installed �� �G •G�
- C�8 Manufacturer's name `���'�'"�
Model Number HP � Volts _v
Length of drop pipe �Q� ft. Capacity g.p.m. -
Type:� bmersible 'J LS.Turbine .-Reciprocating C Jet I 1
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? �Yes�No
VARIANCE
y Was a variance granted from the MDH for this well? � �Yes ��No TN#
�� WELL CONTRACTOR CERTIFICATION p
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 . L� s�
REMARKS,ELEVATION,SOURCE OF DATA,etc. � a7t�OZS Well Drillirtg Co�� IQCs �LJJI
Licensee Business Name Lic.or Reg.No.
�_,� _ '��- // o�
ori d epresentative Signature Date
� Chl2C�C. �C�
} _
, -- — — —
__ _—_— —
s
LOCAL COI'Y 7 3 915 8 Name of Driller
;`� HE-07205-09(Rev.9/05)
�-- IC 140-0020 � _ �
r �
Twi�vv C i,t� litl ac,t"e�r�' C ' ' , I vu'i
y
617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556
OS/o2/2006
Stodola Well Drilling
3841 North Main
Sr. Bonifacius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab#: 4796N
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 07/31/2006 from'the following location:
2180 North Shore Dr.
Orono,Mn
Well#739158
Coliform Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/1
The results of these tes[s indicate that this well is producing water that meets the
stan�ards for F.H.A., V.A., or conventional loans. This reporr is an analysis for
coliform and nitrate only and does nor indude analysis of Lead and other
contaminants. (Unless as specified by client).
fi,a �City Water Ginic, Inc.
� .
�4�`.;;1
Bill V ��da/e
Lab Cert�cation#027-053-119
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