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Home My WebLink Aboutwell info WELL OR BORING LOCA710N MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 10 7114 Counry Name WELL AND BORING SEALING RECORD Mennle90 aoUnique No. Henr�e #.Fi Minnesota Statutes,Chapter f031 or W-series No. P (Leave blank if not known) Township Name Township No. Range No. Section No. Fraction(sm.�IgJ Date Sealed Date Well or Borin Gp�structe �'� Orono 117 23 7 � � � 7/3A/95 S�Y Numerical Street Address or Fire Number and City ot Well or Boring Location 1390 Par� Drive DepthBeforeSealing 7� ft. OriginalDepth � ft. Show exact location of well or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL in section grid with"X". � j location, showing property ingle Aquifer ❑ Multiaquifer �� lines,roads,and buildings. N WELUBORING [�vleasured ❑ Estimated � � � � [�Water Supply Well ❑Monit.Well -�-- --;-- --;-- ❑ Env.Bore Hole ❑Other �ft. $] below ❑ above land surface yy --�- -Y- --;-- --;-- E CASING TYPE(S) � � � --�' -�-- -�-- --�-- � � X € [�6teel ❑ Plastic ❑Tile ❑ Other %mile � -�-- -�-- --�-- --�-- � ��—� CASING Diameter Depth Set in oversize hole? Annualar space initially grouted? llL""" S ""�J"" �f� �w---t mi�e�s, � in.from�_ to�y ft. ❑Yes [�No ❑Yes ❑No ❑ Unknown I I PROPERTY OWNER'S NAME in.from _ to ft. ❑ Yes ❑No ❑Yes ❑No ❑ Unknown Property o ner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown SCREEN/OPEN HOLE Screen from�_to�.� ft. Open Hole from to ft. O B ST R U CT I O N/D E B R I S/F I L L WELL OWNER'S NAME [�Obstruction ❑ Debris ❑ Fill ❑ No Obstruction Well owner's mailing address if diflerent than property owner's address indicated above. Type of Obstruction/Debris/Fill . Obstruction/Debris/Fill removed? [�Yes ❑ No PUMP Type GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed � Not Present ❑ Other FORMATION If not known,indica�e estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �No Annular Space Exits ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to_. ft. ❑ Perforated ❑ Removed Type of perforaror ❑ Other GROUTING MATERIAL(S) GroutingMaterial a�+r+�� ++�a from �_ to� ft. yards _� bags from to ft. yards bags from to R. yards bags trom to ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑ Yes '�No LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. R.E..S. W��ir-nrilling 27276 Contractor Business Name License or Registration No. � �-_ ,� � � / �, 1 i_�._ , !f�.. '�_ 1'e' %�'1/ �(L,.. Authorized Representat�ve$ign'atar�' Date i '- �C��i' '}j�-� �� .!� CL— Name ol Person ling Well or Boring LOCAL COPY �"� ? 0 7 � �. 4 HE-01434-02 10/95R WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. CountyName WELL AND BORING RECORD 5 7 2 71 �. Hennep i n Minnesota Statutes Chapter 103/ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed Orona 117 23 7 ,NW,, SE,,. 200 " 9/�/95 • House Number,Street Name,City and Zip Code of Well Location or Fire Number DRILLING METHUD 1390 Park Dr�ve ❑ CableTool ❑ Driven ❑ Dug ❑ Auger �Rotary ❑ Jetted ' Show exact location of well in section grid with"X". Sketch map of well location. ❑ 4 � / Showing property lines, � roadsandbuildings. DRILLINGFLUID ��tOnit� - N I I I 1 _I_ ___ ___ _' USE ❑ Monitoring ❑ Heating/Cooling i i � i �Domestic _i_ _a_ _i_ _i_ "'"'"'�'�"""""�""� ❑ Irrigation O Community PWS ❑ Industry/Commercial i i i i : ❑ Noncommunity PWS ❑ Remedial w ' f f E� j t ❑ TestWell ❑ Dewatering ❑ t i -, i i �/ZM�a t'f-�""""-"", CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. _i_ _ i_ _L_ _i_ � � ❑ Steel ❑ Threaded ❑ Welded i i i i �Plastic ❑ s �1 Mile� CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME 4 in.to 195h 200 Ibs./ft. $ in.to 64t. Wayne Holmes ,�.,o h. �bs.�n. ��.to�. Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft. SCREEN OPEN HOLE Make +r 3.] C�_� from ft.to ft. Type ��vt� Diam. SIoUGauze Length Setbetween � ft.and ft. FITTINGS: aCke� STATIC WATER LEVEL WELL OWNER'S NAME 7 d itKE] below ❑ above land surface Date measured PUMPING LEVEL(below land surface) Well owner's mailing address if different than property owner's address indicated above. � ?O ft. after 3 hrs.pumping 4 o g.p.m. �ELLHEADCOMPLETION �itewater .S—rJ�� Pitless adapter manufacturer Model ❑ Casing Protection ❑ 12 in.above grade _ ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMATION Well grouted? � Yes ❑ No HARDNESS OF Grout Material ❑ Neat cement �Bentonite ❑ Concrete ❑ igh Solids Bentonite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO from 6� to 6 ft. � ❑ yds. �bags (�'1.�I7 f f 11 brown SC�f t � 3 from to ft. ❑ yds. ❑ bags from [o ft. ❑ yds. ❑ bags tL) SO�1 black j�Q(�� NEARESTKNOWNSOURCEOFCONTAMINATION p 3 4 4� feet � direction g��r ��i'�e' Well disinfected upon completion? C�Yes ❑ No a f Y' teStE,.s('� G'Z�Y broWn ��• `� 27 PUMP ❑ Notinstalled Dateinstalled ��g�96 clay bIL1G H1Ga. �7 �4 Manufacturer'sname Sta"'Rit@ Model number S l 00M HP I voics san:� brown f i ne 6� ��1 Length of drop pipe 1 ft. Capacity 1 5 g.p.m. ' Pressure Tank Capacity sand & gravel brown i8� 2d� Type: f�Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes C�No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes L?�o WELL CONTFiACTOR CERTIFICATION Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. R.E.S. Weii Driliing 2?276 oA� A k`,T , Licensee Business Name Lic.or Reg.No. V 't W { :�� t�-� ��.�: (--- �� , �_� -, Authonzed Representat�ve S�gnature Dafe Robert E. Stodola, Jr. 9/9/96 Name olDriller HE 01205-OS(Rev.1/95) LOCAL COPY � 7�7 i 1