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HomeMy WebLinkAboutwell info f , WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSealH 206581 County Name WELL AND BORING SEALING RECORD Minnesota aoUnique Well No. i # i� Hennepin Minnesota Statutes,Chapter 1031 orraW-series No. Township Name Township No. Range No. Section No. Fraction(sm-)-Ig) Date Sealed Date Well or Boring Constructed Orono 117 23 07 2-0020 ��� 0� GPS Latitude degrees minutes seconds /Z L� LOCATION: Depth Before Sealing ft. Original Depth ft. Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer WELUBORING JyMeasured ❑Estimated 4753 N Shore Dr _ Orono 55364 YvaterSupply Well ❑Monit.Well Show exact location of well or boring Sketch map of well or boring in section grid with"X" to a).on,showing property ❑Env.Bore Hole ❑Other ft. [below ❑above land surface N f? li roads,a ildings. ! n' n CASING TYPE(S) I � i feel ❑Plastic ❑Tile E]Other W E }{' WELLHEAD COMPLETION � Outside: E]Well House Inside: E]Basement Offset f4 mik [�fitess Adapter/Unit E]Well Pit i i - I i t 1 t t r %% ❑Well Pit ❑Buried s C y ❑Buried PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Diameter Depth Set in oversize hole? Annular space initially grouted? Property owner's mails dress if different than well location address indicated abov — If—/—,in n.from_-) to 1,2 ft. ❑Yes XO ❑Yes ❑No E]Unknown X in.from t0 ft. E]Yes No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑ No ❑Yes ❑ No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r � Well owner's mailing address if different than property owner's address indicated above Screen from /26 to_/2 ft. Open Hole from t0 ft. OBSTRUCTIONS yods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction n Type of Obstructions(Describe) _AJ44e=a /_/j�+� 9 4 j"21 GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? S El Describe FORMATION If not known,indicate estimated formation log from nearby well or boring PUMP /�,n �` Type_,50 f\Iu-,m I? drift Cfiemoved �❑ Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: C9.ldo Annular Space Exists ❑ Annular space grouted with tremie pipe El Casing Perforation/Removal JJ�� in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) J/� Grouting Material _ _ mm___6�_to�i4.1.—' yards %[ J 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? XYes 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. Don Stodola Well Drilling Co. , inc. 27172 Contractor Business Name License or Registration No. ljolfor&ed' e resentative Signature - e LOCAL COPY Fi 206581 Name of Person Sealing Well or Boring Jim Antonson WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSealo. H 20658?_ County Name WELL AND BORING SEALING RECORD Minnlesotta Unique Well No. Hennepin Minnesota Statutes,Chapter 1031 or W-series No. (Leflv2 blank it not known) Township Name Township No. Range No. Section No. Fraction Ism i Ig) Date Sealed Date Well or Boring Constructed Orono 117 23 07 2-0020 GPS Latitude degrees minutes seconds LOCATION: Depth Before Sealing S -ft. Original Depth ft. Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ��,,!!'' WELL/BORING Measured E]Estimated [)/ater Supply Well E]Monit.Well /` Show exact location of well or boring Sketch map of well or boring in section grid with"X' to ti n,showinQ�P�operty E] Env.Bore Hole E:1Other _ft. Xbelow ❑above land surface N /t lin os,,,�ndb�^ings. CASING TYPE(S) 7 feel ❑ Plastic ❑Tile ❑Other t xL WELLHEAD COMPLETION Outside: Well House Inside: ❑ ❑Basement Offset )4mile ❑PitessAdapter/Unit Nell Pit ❑Well Pit ❑Buried S r mea ❑ Buried PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) BobDPieper Diameter Depth f Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above ��� / in.from to 1 C1 ft. ❑Yes )<No ❑Yes ❑No ❑Unknown 2 of in.from to ft. El Yes !!�❑El No E]Yes E] No E]Unknown L in.from t0 ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE VI � r Well owner's mailing address if different than property owner's address indicated above Screen from to ft. Open Hole from t0 ft. OBSTRUCTIONS ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill [RAo Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑ No Describe FORMATION If not known,indicate estimated formation log from nearby well or boring PUMP drift 0 50 Type —— --— ❑ Removed CNot Present [IOther 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 Type of perforator ❑ Other GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) �yy r Grouting Material NI/'�/�4rome_toft. 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? es ❑ 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. Don Stodola Well Dri i l inZ Co, . incl ?71 72_ Contractor Business Name License o' egistratron No. ,j 5-12-03 A ori e e nt ri vE Sr natur_ Date /� /� n I'► Jim Antonson LOCAL COPY H 2 0 6 5 8 L Name of Person Sealing Well or Boring WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELL AND BORING RECORD 688985 Hennepin Minnesota Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Orono 117 23 07 % 347 n 5-28-03 GPS DRILLING METHOD Latitude dNpWegrees minutes seconds _ L ail Logrees minutes seconds ❑Cable Tool El Dug ❑Auger >Fiotary Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑ 4753 It Shore Dr, Orono 5536 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Shop exact location of well in section grid with"X". Sketch map of well cation. water FROM ft.TO ft. Showing prope y lines, N roads and t jildings USE ❑Monitoring ❑Heating/Cooling Domestic ❑Environ.Bore Hole ❑Industry/Commercial ❑Noncommunity PWS ❑Irrigation ❑Remedial ❑Community PWS ❑Dewatering F-1 CASING vt HOLE DAM. w E t• [ Dn a Shoe? ,files ❑No T Threaded ❑Welded ��e(J. Steel ❑Plastic ❑ '/s Mile --- ----'------- I CASING DIAMETER WEIGHT S l \\ F1 Mile ,!f/ _ T� PROPERTY OWNER'S NAME/COMPANY NAME V ` in.to ft. IbsAt. 3U&to Bob Pieper SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. Make FROM 33Sft TO-41147—ft. same as above Type Diam. Slot/Gauze Length Set between ft.and ft. FITTINGS STATIICC©TER LEVEL 7 ftv,/below ]above land surface Date measured 5-28--03 PUMPING LEVEL(below land surface) WELL OWNER'S NAME/COMPANY NAME 210 ft.after hrs.pumping 40 g.p.m. WELL HEAD COMPLETION Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer Vbj tgInSt Model ❑Casing Protection �12 in.above grade ❑At-grade(Environmental Wells and Boring ONLY) GROUTING INFORMATION Well grouted XYes ❑No Grout material ❑Neat cement ❑Bentonite ❑Concret.XHigh Solids Bentonite from 0 to ft. _ 10 ❑yds. Bags from to 8 ft. n& + l❑ft Irags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. ❑yds. ❑bags MATERIAL 7 NEAREST KNOWN SOURCE OF CONTAMINATION fill brown soft A t �- feet /fj direction typa V �! Well disinfected upon completion Yes ❑No clay yellow soft 4 38 PUMP �/� j_ ❑Not installed Date installed 9-29-0Ae 3 motor clay gray soft 38 70 Manufacturer's name /� Model number HPI Volts 230 clay/sand g ray soft 70 134 Length of drop pipe 126 ft. Capacity _ g.p.m. Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ clay gray soft 134 234 ABAADONEDWELLS Does property have any not in use and not sealed well(s) ❑Yes 0W. fine sand gray soft 4 320 VARIANCE g 9 Was a variance granted from the MDH for this well? Yes E:]No TN# x.15 clay/gravel gray soft 320 338 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. limestone Use asecobVaX0e,ded hard 338 347 REMARKS,ELEVATION,SOURCE OF DATA,etc. Ikon Stodola Well- 11K 111.0. - 1ne � 72 Licensee Business Name 1c. r Reg.No. ;ul d e e nlh &qn.&,�r, Chuck_ Moore 5-28-03-___ LOCAL COPY � 688985 Name of Driller Date HE-01205-OB(Rev.5/02) IC 140-0020 riv�v C Xy W abeor C U , Irwx. 617 13th Ave So • Hopkins, Minnesota 55343 (612) 935 - 3556 06/05/2003 Stodola Well Drilling 3841 North Main St. Boni facius MN 55375 938-2111 REPORT OF WATER ANALYSIS Lab#: 443 Our Laboratory reports these analytical results, determined on a sample taken by CLIENT on 06/02/2003 from the following location: Bob Pieper 4753 N.Shore Dr. Orono,Mn Unique Well#688985 Coliform Bacteria <1/100 ml 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). City ater Clinic, Inc. Bill s le Lab Certification#027-053-119 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSealo. H 215053 County Name WELL AND BORING SEALING RECORD Minnlessong tta Unique Well No. in Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank,f-known) Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed Orono 117 23 07 32-0020 GPS Latitude degrees minutes seconds Of / LOCATION: Depth Before Sealing `� ft. Original Depth / ft. Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer L q !T t+ WEELLUBORING )(Measured ❑ Estimated 47 3 1� Shor , Orono [Water Supply Well ❑ Monit.Well ` Show exact location of well or boring Sketch map of well or boring Ire in section grid with"X" Env,Bore Hofe Other ft. (Xelow above land surface ,',cation,sho roperty E] Env ❑ N `limos,rod-ad' n b ngs. /1V CASING TYPE(S) Xteel ❑Plastic ❑Tile ❑Other W -- - - -- -i-- -- -- E WELLHEAD COMPLETION r , L-- , Outside: ❑Well House Inside: E]Basement Offset km's N ]SPitlessAdapter/Unit ❑Well Pit ❑Well Pit El Buried S mAe - ` ❑Buried PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Bob Pieper Diameter Depth r Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above If in.from to ft. Yes LINO ❑Yes ❑ No ❑ Unknown 3 of 3 in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑ Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑ Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r Well owner's mailing address if different than property owner's address indicated above Screen from_ /6n to ft. Open Hole from to ft. OBSTRUCTIONS ods/Drop Pipe ❑ Check Valve(s) ❑ Debris j�❑ Fill E] No Obstruction Type of Obstructions(Describe) ��1,1% �/'9 4- i GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes El No Describe FORMATION If not known,indicate estimated formation log from nearby well or boring — PUMP Type ❑ Removed [ Not Present ❑ Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: )/No Annular Space Exists El Annular space grouted with tremie pipe ❑ Casing Perforation/Removal f in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) Grouting Material /v+'` [ IZK& rnm__ tol�L.L 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 information contained in this report is true to the best of my knowledge. Don Stodola Well Drilling; Co., Inc. 27172 Contractor Business Name License or Registration No. ;eK4�� 11-19-03 uth ize epresentative S ure Date LOCAL COPY H 215 0 5 3Jim Anton Name of Person Sealing Well or Boring