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Home My WebLink Aboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BORINI�G NOWELL Co�ntyName WELL AND BORWG RECORD .� � �� H Minnesota Siatutes,Chapter f037 Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Q ,� ,� y, tt. GPS DRILLING METHOD LOCATION: Latitude _ degrees minutes seconds Longitude degrees minutes seconds ❑Cable Tool ❑Driven U Dug ❑Auger �Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number � DRILLING FLUID WELL HYDROFRACTURED? ❑Yes No Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. �.teC From ft.To ft. . Showing property lines, ; N �a��uildings,and direction. USE �'Domestic ❑Monitoring ❑Heating/Cooling ` ��. � __i___ __1_____i_____i__ ..� � ❑Noncommunity PWS L�Environ.Bore Hole �]Industry/Commercial ; ❑Community PWS (J Irrigation ❑Remedial �-� --i--- --`-- ---F-----'-- ❑Elevator �]Dewatering ❑ '� � �� ' , , , , E� _ CASING MATERIAL Oe� �a HOLE DIAM. , , , , �':Y� Dr �. ive Sh ❑Yes � --+--- ---'--- ---F-----*-- r \`�- ❑Steel ❑Threaded ❑Welded � , , , Mile StiC . , , . I ; ,�Pla ❑ --�--- --�-----�—---%- � ' ' 1 CASING � � S � � , x�� Diameter Weight Specifications I �7 �1 Mile—� �in.to �.Q/ ft. �.� __Ibs./ft. Alii'R! �_in.to�.ft. PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. �in.to��ft. " T("� �■�tZ in.to ft. Ibs./ft. in.to ft. Property owner's mailing address if different than well location address indicated above. SCREE♦N�_L___ OPEN HOLE .. 25$ �T'�mpt PL8�� Make alVli� From ft. To ft. �� ` Type }4}'R��'t�AfRII At*� Diam. �� Or�> I�t 55356 SIoUGauze �1'14[l Length_1.��,'��i Set between ft.and ft. FITTINGS STATIC WATER LEVEL Measured from � ft.�Below ❑Above land surface Date measured_�wZl�� WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) � 1� ft.after 1�5 hrs.pumping � g.p.m. ( Well/boring owneYs mailing address if different than properry owner's address indicated above. WELLHEAD COMPLETION Ry,� E �Pitless/adapter manufacturer �ju�e�te`� � Model i ❑Casing Protection �2 in.above grade � ❑At-grade(Environmental Well and Boring ONLY) ' GROUTING INFORMATION . Well grouted ,{�Yes ❑No ,�( Grout materials [�Neat cement ey.Bentonite ❑Concrete ❑Other From Q To � ft. �_ ❑Yda �Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From � To�RI$T.ural fift]ji'ds. ❑Bags MATERIAL From��T � ❑Yds. ,�Bags ♦ NEAREST KNOWN SOURCE OF CONTAMINATION Cia}1 gray ft � W f.�� _teet �"' direction s-��,,,,>>`x+ryp �p� ��rp/� Well disinfected upon completion? �Yes ❑No �,,.,,_ '��,�;,3'-a._.e� '"""' 'p�$,y fC VlJ Z�S PUMP t [�_�Not installed Date installed__ . " Manufacturer's name �t�'lOt�C Model Number HP�� Volts �-^� Length of drop pipe �� ft. Capacity __g.p.m. Type:�Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ 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 Rules,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. �tE�EIVED � Stodola Well Dri2ling �o,. Inc. 1b91 Licensee Business Name Lic.or Reg.No. � ��;' DE� 31 2007 � � � � : � :, i2-i�-o7 i resentative ignature Certified Rep.No. Date LOCAL COPY 7 �0 6 9 7 -- `�` '`�°`� Name of Driller IC 140-0020 HE-01205-10(Rev.6/O6) 7�wi�vv Ci�t� 1Nat��v' C ' ' , I v��c'i. y 617 13th Ave So � Hopkins, Minnesota 55343 • (612) 935 - 3556 12/13/2007 Stodola Well Drilling 3841 North Main ' Si. Bonifacius MN 55375 938-21 1 1 REPORT OF WATER ANALYSIS . Lab #: 583BN Our Labora[ory reports ihese analyrical resulis, derermined on a sample taken by CLIENT on 12/1 1/2007 from the following location: Tom Lutz 3570 north Shore Dr. Orono,Mn Well 750697 Coliform Bacteria Absent Nitrates Nitrogen <1.0 mg/! The resulis of these tests indicare thar 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 contaminanrs. (Unless as specifed by client). Twin Ciry�yVater Clinic, Inc. ' �1 . r ..:.. ;,: ,. �< /� Bi�` Va"►f�rsdale � Lab Certification!!027-053-119 �/VELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I„I �}�C/9 � County Name WELL AND BORING SEALING RECORD Minneso a�Unique Well No. �, g'•�r �p�� Minnesota Statutes, Chapter 103I or W-series No. (Leeve�lenk it not knownf - Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed t}rc�o I17 2 U8 34-Q�U19 // ,��. �j i GPS Latitude degrees_._ minutes seconds Depth Before Sealing I � ft. Original Depth ft. LOCATION: Longitude _ degrees minutes seconds A�UIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer � � _ 3570 North Shore Dr �� 55391 WE UBORING �Measured [)Estimated Date Measured�� - � � �Water-Supply Well ❑Monit Well �f�' " Show exact location of well or boring ap of well or boring � Env.Bore Hole in section grid with"X:' location showing property �-� ❑Other ,,,� ft. �below ❑above land surface N lines,r ds,and buildings. CASINGTYPE(S) . 1 ; I � � `, �, Steel ��Plastic ❑Tile ❑Other --'-----�--- ---�-- ---`-- � WELLHEAD COMPLETION , W ; ; : ; ET "�,�� . __;___ __�___ __�_____r_ Outside: ❑Well House ❑At Grade Inside: y��,/Basement Offset 'h Mile ❑Pitless Adapter/Unit ❑Buried _I well Pit --;--- --.--- ------------ 1 ❑Buried ' ' S ' ' ��f Well Pit �-1 Mile� � �_,, � �,� []Other ��Other /�I`�-,�r.l�__ _ P OPERTTy�O�WNER'S NAME/COMPANY NAME CASING(S) �� ++�+=Z Di�eter ` Depth _ � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above �� •...• in.from� to��ft. ❑Yes �No ❑Yes ❑No ❑Unknawn 258 Cyr�et Ple�ce 0�� 5535b in.from to ft. ❑Yes [;No ❑Yes ❑No ❑Unknown f in.from to _ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown � WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE � / t Well owner's mailing address if different than property owner's address indicated above SCreen from f.:.-`� to �� ft. Open Hole from to ft. OBSTRUCTIONS [,l Rods/Drop Pipe �]Check Valve(s) j�Debris ��Fill �o Obstruction 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. r�� Type P--' %`� ❑Removed �Not Present ❑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 [J Casing Perforation/Removal in.from to ft. i�Perforated I�Removed in.from to ft. ❑Perforated �i Removed � f Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) _ � A ' ..� .� GroutingMaterialiVf/—J/ �/�'<<l��from� to �� ft. _ yards J bags from to ft. yards bags from ro 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?_ 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 Stodola Well Dril2ing Co., Inc. I691 Licensee Business N e ., License or Registration No. �� !'�� I�J � i..' �lI i" t Representative Signature Certilied Rep.No. Date {'�� ; 664 55 �.'�-� ,�.,� � z LOCAL COPY H � �L� Name of Person Sealing Wel/or Boring HE-01434-10 IC#140-0423 5/07R . i