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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
� �o��tYName WELL AND BORING RECORD 6 5 5 010
Hennepin Minnesota Statutes Chapter f03/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
u Ol'Oi1� �.1.7 �� Q�i �i. �i. �i. n.
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
4 5 5 Sus s ex Lane E}r011� 5 5 3 5 ❑ Cable 7001 ❑ Driven i I Dug
� Cl Auger �Rotary f� Jetted
�. Show exad location of well in section grid with"X' Ske�dh map of well location. f� __.____ `:
���/Showing property lines, �- ��
roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �M110
N _ �\
� � � � -
,� _._ _ �a t e r FROM n.�o h
-,- -,- -,-- -,- ,..
USE ❑ Monitoring ❑ Heating/Cooling
� i i i � �Domestic
❑ Community PWS ❑ Indust /Commercial
_i_ _�_ _�_ _i_ ❑ Irrigation ry
i i i i ❑ Noncommunity PWS ❑ qemedial
w i l e T _ ❑ Environ.Bore Hole ❑ Dewatering ❑ _
-i- -,- -r- r ��ZIM1e CASING Drive Shoe? � Yes C�No HOLE DIAM.
_i � i �_ I ,� ❑ Steel ❑ Threaded � `C7 Welded
_ ___ _ _ _ 1
�'Plastic ❑
s �
�1Mile� f
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME �in.to���ft. ��� Ibs./ft. � �
in.to tt.
2on Eiden C�• in.to_ fl. IbsJfl. m to��_��.pp ft. z
�' Property owner's mailing address if different than well location address indicated above. __in.to_____R. __,_____. Ibs./ft. �in.to' ft. �
4100 A�rkshi re LCine SCREE�IO On OPEN HOLE
Plymouth, 1KNN 554�6 Make •� � _ from ft.to ft.
Type $�$�f 1e.9$ SC�el _Diam. _
SIoUGauze ��,�n Length �� ♦ 4 f
Setbetween �_J� ft.and_�_�_tt. FITTINGS: '�rv'�/1'» e.:�b�y
Y
STATIC WATER LEVEL
WE�L OWNER'S NAME ��__ ft. 9.below ❑ above land surface Date measured 6_�
��
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. t �f'f ry, after �f hrs.pumping__��__g.p.m.
--Z G T-
WELL HEAD COMPLETION __y,
�Pitless adapter manufacturer w������..��_ Model ._ .._
❑ Casing Protection__ _ �.12 in.above grade
❑ At-grade(Environmental Wells and Bonngs ONLY)
GROUTING INFOFMATION
Well grouted? �'Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement ❑ Bentonite r7 Concrete �High Solids Bentonite
MATERIAL from�to ��ft. 2_�S_ _ ❑ yds.f�'bags
from to ft. � d�.� bags
--�$— —��� A8 t IIIB� �i
from to ft. yds. bags
NEAREST KNOWN SOURCE OF CONTAMINATION
�j feet __ ��_.►L direction �_type
Well disinfected upon completion? �Yes ❑ No �
't
PUMP
❑ Not installed Date installed_�_���,_��
Manutacturer's name
Model number HP � Volts__._¢���
�•! LJV
�` Length of drop pipe�7 _ ft. Capaciry ._g.p.m. _
_ Type:�Submersible ❑ LS.Turbine Cl Reciprocating ❑ Jet ❑ _____
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes �No
VARIANCE
jWas a variance granted from the MDH for ihis well? 17 Yes �No TN#__
WELL CONTRACTOR 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,eta The information contained in this report is true to the best of my knowledge.
' Don L�edola_ Well Dr�,lling Co.; In�. 2 172 ;
Licens Business Name - L� r Reg.No. �
�' � 1��1'�(?� `
u o e R rese iv ignature Date �
Chuck Moore 9—ZI-0�
Name ol Driller. Date t
LOCAL COPY 6 5 5 010 HE-01205-07(Rev.2l99)
/ . . ti
rw i�v C i,t�y litl at�.v' C ' ' , I v�,c�
617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556
09/25/2000
Stodola Well Drilling
3841 North Main
St. Boni facius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab#: 383
Our Laboratory reporis these analytical results, determined on a sample taken
by CLIENT on 09/21/2000 from the following location:
Tony Eiden
455 Sussex Lane
Orono,Mn
Unique Well#655010
Coliform Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/1
The results of rhese tests indicaie that ihis well is producing warer thac meets the
siandards for F.H.A., V.A., or conveniional loans. This reporr is an analysis for
coliform and nirrate only and does not include analysis of Lead and oiher
contaminants. (Unless as speci�ed by client).
�
" Ci Waier Clinic, Inc.
`�
Bill ale
Lab Certilication k 027-053-I 19
4