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; WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINN�bTA�i�I(7tltl�i L NO.
� County Name WELL AND BORING RECORD
Minnesota Statutes,Chapter f031 ,����
'� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
tt i,ITY F S? N
- GPS � � �
Latitude degrees minutes seconds DRILLING METHOD
' LOCATION: ---
.= Longitude degrees minutes seconds ❑Cable Tool �]Driven � -�Dug
t ❑Auger �Rotary ��Jetted -
House Number,Street Name.City,and Zip Code of Well Location or Fire Number J
DRILLWG FLUID WELL HYDROFRACTURED? �,]Yes -1 No
Show exact location of well in section grid . Sketch map of well bcation. Aa�EC FROM ft.TO ft.
. `� ' Showing property lines, --
_ N � �'�, roads and buildings USE -�- �-. :
-- � � _Monitoring J Heating/Cooling
`� � � � � ' Domestic �Environ.Bore Hole ❑Industry/Commercial
� --'-- --' -`----`-
�,_ ; ; j j �� oncommunity PWS ❑Irrigation �J Remedial
�,� N ` •
I I I ; � I �Community PWS ❑Dewatering ❑
'--- ' - ---` `- :.
, � CASING HOLE DIAM. �
- w , e T �' � Drive Shoe� [�.]Yes �No �
�� -,---, ---�-- ;-- I `, ❑Steel r Threaded [Welded ��
� , , , , Mile ` -
,h �- � ` - Plastic •
------------ ------ --.-- 1 ,,,
'�� • �� CASING DIAMETER WEIGHT
S * e� 4 p A .
� in.to s�` ft. ���1 Ibs./ft. O in.to ���ft
i 1 Mile -�
� PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./fl. in.to ft.
St ructural IIAR'g� SCREEN OPEN HOLE
Proper?y owner's mailing address if different than well location address indicated above. Make p ��t FROM ft. TO ft.
I405 �1 Lilac Dr, a�ftt' G26 Type PLBC_._ Diam.
' ��ld�n Valley, r71� 55�22 SIoUGauze ����__. Length�j_.,�.�___
Set between ft.and it. FITTINGS n M
STATIC WATER LEVEL
`-'� fL�elow ��]above land surface Date measured �1�2`�4
PUMPING LEVEL(below land surtace)
°� WELL OWNER'S NAME/COMPANY NAME j .
a 70 ft.after � hrs.pumping �S
g.p.m.
WELL HEAD COMPLETION y.,�
�. Well owner's mailing address if different than property owners address indicated above. itless adapter manufacturer �j,� --�t[ �.3,r. Model
� .Casing Protection -'��. 2 in.above grade
��At-grade(Environmental Wells and Boring ONLY) � �
GROUTING INFORMATION
Well grouted �J Yes ❑No
Grout material �,_Neat cement ��Bentonite ;J Concrete�'High Solids Bentonite
from O to �Oft. � ` yds. bags
from 3� to �72ft. QStL1C$�;��ags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to fl. �
MATERIAL []yds. �. ;bags
NEAREST KNOWN SOURCE OF CONTAMINATION
�.'18y 3Te�,1�W $�f t Q j 6 ��1 � --feet ,�`"�,,,. direction _ T - �YPe
Well disinfected upon completion Yes ❑No �
clay gcay aoft 16 60 PUMP
/ � _ �f
�Not installed Date installed ! � ' � �
sand �C'$�T $Q�t �j� i 1 O Manufacturer's name . �•�-..�.•�•�,.....-r�'�""'-'
Model number HP � �1 Volts .�'x�.��
rg $�l� 11� �70Len thofdro f
C�8y � Y 9 P P�Pe �;��L�'j ft. Capacity g.p.m.
1 p Type:F � Submersible [:�LS.Turbine ❑Reciprocating ❑Jet ❑
' watersand brorat� $�f�' y7� 1pO"ABANDONEDWELLS
Does property have any not in use and not sealed well(s) ❑Yes No
VARIANCE
Was a variance granted from the MDH br 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,SOUFCE OF DATA,eta !1(�n a7 t wifitta We I 1 D r i 11 i ng Ca., i QC Z �(��
Licensee Business Name Lic.or Reg.No.
�
/� __ .. : ,, ..� , �
l�:..:�"�� ._�a��� i;,/�
a e Date
Chuck Moare
Name of Driller
LOCAL COPY 7 � � � � �
HE�01205-08(fiev.5/02)
� IC 140-0020
�- • �
�wi�vv Ci�t� 1Nat�' C ' ' , I��,c�.
y
617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556
ll/04/2004
Stodola Well Drilling
3841 North Main
St. Boni facius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab#: 861
Our Laboratory reporrs these analytical resulrs, determined on a sample raken
by CLIENT on 1 1/02/2004 from the following location:
440 Stubbs Bay Rd.
Orono,Mn
Unique Well #711478
Coliform Bacieria <1/100 ml
Nit-rates Nirrogen <1.0 mg/1
The resu/ts of these tests indicate Chat this well is producing water ihat meets the
standards for F.H.A., V.A., or conventional loans. This report is an analysis for
coliform and rriiraie only and does nor include analysis of Lead and other �
contaminants. (Unless as specifed by client).
�;QTwin City Water Clinic, Inc.
;.'.�:,, ,
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�
Bi Arsdale
�
Lab CeRification#02�-053-119