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WELI L�CATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WE
our.ty�ame WELL AND BORING RECORD
� ���'�-� Minnesota Statutes Chapter 103/ 5 8 0 4 0 6
Township Name Tow sf�ip No. Rangg,y,o. Section No. Fraction WELL DEPTH(completed) Date Work Completed
L'Y'.`i'tt� � 1I LJ I's[1 �$�� n. fi—�—��
v, i. v.
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
3�.`��•' ��i�.r�t �11� �,U�Q �1. �?�1 �'��� ❑ Cable Tool ❑ Driven ❑ Dug
� ❑ Auger O Rotary ❑ Jetled
Show exact location ot well in section grid with"X". Sketch map of well location. ❑ j
Showing property lines, �
roads and buildings. DRI�LING FLUID �
i
N �
I I I I � �
I I I I L
1(�� USE ❑ Monitoring O Heating/Cooling
i i i � f�Domestic ❑ Communi PWS
❑ Irrigation h' ❑ Industry/Commercial
; , ; i � Noncommunity PWS ❑ Remedial
yy E� �. ❑ Test Well ❑ Dewatering ❑
i i i i
i i i -r CASING Drive Shce? ❑ Yes ❑d+lo HOLE DIAM.
VzMna
� i _L i_ I t � ❑ Steel ❑ Threaded ❑ Welded
-i -i- i i � ! v)
�iPlastic ❑
s
�1 Mile� �
�1 CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME � in.ro � ��ft. Ibs./ft. � i����t ��{
�C.3�..''T'� L1:rxi.Cj ���� � (,
� �.t�� � t�.
in.to ft. �bs./R .
Property owner's mailing address if different than well Ixation address indicated above. in.to ft. Ibs./ft. in.to_ft.
L_.'..�i�I S E3ZCLC�'�sG^�'�.I,.-r:i ��:y'�{� SCREEN_��_ OPEN HOLE
Make from ft.ro ft. -
S�lOY'�WCX:f�� �1. J�J��. TYPe � �il E�SS �E.'t-_'i Diam. .-n
SIoUGauze ��l�}�,.` Length �S!
Set between ��ft.and i r!f;ft. FITTINGS: �(i� �{ :�u
STATIC WAT LEVEL
WELL OWNER'S NAME � fl. Lj�below ❑ above land surface Date measured �3 �����
PUMPING LEVEL(below land suAace)
Well owner's mailing address if diflerent than property owner's address indicated above. ft. after hrs.pumping g.p.m.
WELL HEAD COMPLETION
C�Pitless adapter manufacturer �������r Model
❑ Casing Protection ❑,l�in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? C�Yes ❑ No
HARDNESS OF Grout Material ❑ Neat ceme . O Bentoru g-, ❑ Concrete d�k�igh Solids Bentonite
GEOLOGICAL MATERIAIS COLOR MATERIAL FROM TO `�: 3E: L
from to � tt. ❑ yds. �bags
� i -y i from to ft. ❑ yds. ❑ bags
7�t�i1/Clay $lar.3c� ::��r S i 1.�.
from to ft. ❑ yds. ❑ bags
NEAREST O�yyN SOURCE OF CON�MINATION �j �^ �
�s2 c:�,'E.'�. t}.�`��Y � �.;+��� �� � �� feet -� �J✓1 l'� direction '..���.J�1�
Well disinfected upon completion? O}�es ❑ No
:���r��/fine tc tn�:c `T��n �r3 l�t�
, :� ,�J .,
PUMP ^�
� ^r ❑ Not installed Date installed !^�'"`��
, `J�i.�T�.��2.3.Z1t� �C? T�1 "�'t'1T3 3 � t{;; �� �Manufacturer's name �tit"lyj��
Model number ���1���L� HP_.�_ Volts �3{� -
Length of drop pipe j U4� ft. Capacity �f'• g.p.m.
Pressure Tank Capaciry }i�{���1(^rj), (���,].V
Type: o;Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Dces property have any not in use and not sealed well(s)? ❑ Yes LI�o
VARIANCE
Was a variance granted from the MDH for this well? O Yes O}�!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. The information contained in this report is true to the best of my knowledge.
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Licensee Busine s Name Lic.or Reg.No.
/! ,� �s^��y������ �3"�—��3
7 ,�`�_ �
Authonzed Representative Signature Date
C�Ll�k �:�C�Yt� €3--�—r9fi
(''� �a Name ol Driller Date
� �� - � ' � `"�"'�� � `� ��� �'� ��''# HE-01205-05(Rev.1/95)
< <�- �w�n c��� �ua�� c���, ��.
617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556
06/13/1996
Stodola Well Drilling
15306 Hwy 7
Minnetonka MN 55345
938-2111
REPURT OF WATER ANALYSLS
Lab�: 29853
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 06/a4/1996 from the fdlowing location:
3010 SOMERSET LANE
ORONO,MN
UNIGUEM 680406
Cdifam Bacte�a <1h00 ml
Nitrates Nftr+oeen <1.0 mg/I
The results of these tests indicate that this w�ell is producing water that meets the standards for
F.H.A., V.A., or oonventional loans. This report is an analysis for coliform and nitrate only and
� oes not incl�de analysis of Lead and other contaminants. (Unless as specified by dient).
y ate Clinic, Inc.
Bill
ao.b�al labor.tay coomMmg a�O„�
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Lab CertQ'�i 027-053-119