HomeMy WebLinkAboutWell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
��- CountyName � WELL AND BORING RECORD Q
� ���i�'�F�r� Minnesota Statutes Chapter 103/ � v 0 � � �
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(comple[ed) Date Work Completed
n.
t�rr��c 31% ;:i ua ,�. ,�. �. i�`� ' �-�;- 9i
House Number,Street Mame,City,and Zip Code of Well Lceation or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Du
!_��1�"' :�C'T�l�rSf?� L�ne �T�C�I� T'!� `?;:.i.`'.� ❑ Auger ❑Wotary ❑ Je ed
Show exact location of well in section grid with"X". Sketch map of well location. ❑
L j� � S wing property lines,
f � r ds and buildings. DRILLING FLUID
N ��� �ta:i i t:�
� � i � '` , t.
__ ___ ___ _�'
� �'' USE ❑ Monitoring ❑ Heating/Cooling
i i � i X J�,j Domestic ❑ Community PWS ❑ Industry/Commercial
' _i_ _�_ _�._ _i_ ❑ Irrigation
n, i � i i ❑ Noncommuniry PWS ❑ Remedial ,�
y,r E ❑ Test Well
i � � � ❑ Dewatering ❑ .
i i -r -� ��ZM,� CASING Drive Shce? ❑ Yes ❑ No HOLE DIAM. �`
1 ❑ Steel ❑ Threaded ❑ Welded
—� � —L— —�—
i i i i
�,Plastic ❑
S
�-1 Mile-�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME `' in.to � ��� ft. `�DK.i� Ibs./n. % ���� .�{��
C:h���_E'_:a C:11EiCt C:U.
in.to ft. Ibs./ft. �_��{oiL��j'
Property owner's mailing address if different than well location address indicated above. in.to fl. Ibs./ft. in.to ft.
�8�G WtJC}�fG1cT�E DZ'�_V-G' SCREEN ��� OPEN HOLE
$�ICiCtL21,312r''y� MII. J�1 L.� Make � from F ft.to n.
Type +✓��.1.I1.�.E�',r''S.`'.� acs't�f.-'�. Diam.
Slot/Gauze ���/�i; Lengih
Set between ��__ft.and�t u�,Sft. FITTINGS:
STATIC WATER LEVEL
WELL OWNER'S NAME ��� ft. �below ❑ above�and surface Date measured �_`�•`t'} �
PUMPIrjG LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. � ��J ft. after j hrs.pumping •=t'' g.p.m.
WELL HEAD COMPLETION
❑�iUessadaptermanufacturer ��31.F.�Wc',.t�'.� Model
- ❑ Casing Protection OX12 in.above grade
❑ At-grade(Environmental Welis and Borings ONLY)
GROUTING INFORMATION
Well grouted? C�Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement O�entonite ❑ Concrete ❑ High Solids Bentonite
MATERIAL from � ro=���_R. �_ ❑ yds. C]�bags
�,,�1� f��# r a from to ft. ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
NEAREST/KN�0/1dAl,$OUFCE OF CONT�91dlNATION �("� ^^��`` /`�,
�1 r3�' Y��.l.��•Sn `� � L�} �//=�' feet --'�' G%✓�� '"'`���Y
direction pe
Well disinfected upon completion? �Yes O No
CL:.�y Gx�n� ��; �_�
PUMP
❑ Not insta�led Date installed ����� f
S�3nci-G���ii el 7�:I1 �� ��`, � INanufacturersname ta�ZT;t:?�OZ
Model number HP_��_Volts ��(�i
Length of drop pipe�L,� � ft. Capaciry t t g.p.m.
Pressure Tank Capacity �L
Type: �Submersible ❑ L. .TuP6ine -Reciproca mg �Jet ❑
ABANDONED WELLS
Dces property have any not in use and not sealed well(s)? ❑ Yes Cl�lo
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes ❑�o
WELL CONTRACTOR CERTIFICATION
Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF DATA,etc. 7he information contained in this repon is true to the best of my knowledge.
L�c:;:v �`I:'UI}CiLr� tid�LL I?�tILLZIkiG CC), , TAIC.
L�censee Business Name Lic.or Reg.No.
� " 211 i�
r`�J � ��'� �-�-�i
Authorized RepresentafiJe Signature Date
CZ'�r 1�E'1�?�r �;_.�;__� i
� ,.� r � y.. Name olOr/ller Date
a
. . . .. : �.. °�.� �.. � ..��� s.,,.�4
�- HE-01205-05(Rev.1/95)
_ � Jurin �i� UVater ��inic, �nc.'
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617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 -3556
04/12/1987
Stodola Weli Drilling
15306 Hwy 7
Minnetarika MN 55345
938-2111
REPORT OF WATER ANALYSLS
Lab#�: 32345
:
Our Laboratory reports these analytical results,detemtined on a sample taken
by CLIENT on 04/08/1997 from the following location:
Charles Cudd
2805 somerset Lane
, Orono�Mn
Unique iMell*580b85
� Colifam Bacteria <1/100 ml
The results of these tests indicate that this well is producing water that meets the standar�ds for
F.H.A., V.A., or conventional loans. This report is an analysis for coliform and nitrate only and
does not indude anelysis of Lead and other c�taminants. (Unless as speafied by dieM).
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' ; ' ater Clinic, Inc.
��
Bill V
�h'��r c�a�id�s,�io.er
wa«adtr;.xe.�eab HaYr w�er c�eotial.
I.�b Ca�doo/027-033-119