HomeMy WebLinkAboutwell info �' � MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
WELL LOCATION
CountyName WELL RECORD 4 7 g� �� �
i�F:�ll�rE:�.,:1.�i Minnesota Statutes Chapter 1031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date of Completion
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� y. " _ . " . 3 � "�„{.. . _.
1.:�(al�.t i . � �. � v�..�.j7ry �-.Y' y. _.
Numerical Street Address or Fire Number and City of Well Location DRILLING METHOD
�� Cable Tool �� Driven _ Dug
'.'� .-�.i...`:i.��E�_:�. iiC. � i�.i.� .t(;r "'ty-;. i:: Auger �ri� Rotary Ci Jetted
Show exact location of well in section grid with"X'. Sketch map of well location.
Showing property lines, �
N roads and bwldings. DRILLING FLUID
I � _i _i_ >'' :'" _,_..._
.'r- y- i � ... . .
i � i i � USE �
--+- -;- �- �- � s Domestic Monitoring ❑ Heating/Cooling
W � ' � ' E - Irrigation i 7 Public 1 Industry/Commercial
�
_1_ _1_ _'_ __ T y ❑ Test Well � Dewatering _
� ' L
I � f"^Q , CASING Drive Shoe? �'.Yes � No HOLE DIAM.
--�- �- � —�� I �`� G Steel � Threaded ❑ Welded
, 1 `-
a�f � Plastic f l
1----1 mile—� �"
" ����"� CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME in.to ��- �ft. f''• ' Ibs./ft. �in.to�ft.
v j tJl':;:� :��f�_!�l f;s : _.: in.to ft. Ibs./ft. in.to ft.
Mailing address if ditterent than property address indicated above. in.to ft. Ibs./ft. in.to_ft.
SCREEN OPEN HOLE
.. t n>:.. •K?}'�F= .�'.:.G: Make Cy�'u`i`>C'i:x from fl.ro ft.
� _..i� .._.:i . .._ � �,. ., _ �_ _, Type `.'i'Cu�ii � :.f:<�_ Diam�ss —
SIoVGauze � r,_Length �
Set between ��'�� ft.and `` ft. FITTINGS: �
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STATIC WATER LEVEL
" FORMATION LOG COLOR HARDNESS OF FROM TO �`"� ft. ❑.;below ❑ above land surface Date measured "'� �`,""
FORMATION .,
' PUMPING LEVEL(below land surtace)
r�. , -� F �� ,
:J j.:{Y; � c ?�;:( Y t - �,'' ft. after hrs.pumping a.p.m.
i ; , { WELL HEAD COMPLETION }.;`._-�,�� `-{.,,..�.
�:;��1;r- �:.. t '�_ q Pitless adapter manufacturer - Model
i 1 Casing Protection
GROUTING INFORMATION
Well grouted? �;Yes ❑ No
Grout Material .L] Neat cement ❑ Bentonite
^ from to ft. ❑ yds. p bags
from ro ft. ❑ yds. ❑ bags
irom to tt. ❑ yds. ❑ bags
NEAREST SOURCE OF POSSIBLE CONTAMINATION
feet direction rype
Wel�disinfected upon completion? .,p Yes [=i No
PUMP
C Not installed Date installed �`�`' ' '
Manufacturer's name �'Y-5-�'`''�Y
„
Model number HP 1.='� Volts .
Length of drop pipe ft. Capacity �'` a.p.m.
� ; �.
Pressure Tank Capacity �«='. l�:=''-. <-,`'�
� Type: C'y._Submersible ❑ L.S.Turbine � Reciprocating � Jet ❑
ABANDONED WELLS
� Not in use and not sealed well on property? I 7 Yes �"No
+ � C_ -
WELL CONTRACTOR CERTIFICATION
This well was drilled under my jurisdication and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Use a seaond eet'nee� � ._ ;L� _ `' r e.%3 � _ `;�(,, `i;; 7',i., .i ', i:
REMARKS,ELEVATIO RC OF A , c. Licensee Business Name � *L�c.or Reg.No.
-::.� ��= �.�; �. ,. �: _ .
� A�'uthorized Represenfative Siganture � Date
� . . '�`�i.: . �x . - ��a-�'G,
Nameo�Oriller Date ' �
LOCAL COPY '-} i � J � � HE-01205-03(Rev.9/91)
. . ,
TWIN CITY WATER CLINIC, INC.
61? 13th Ave. So.
Hopkins, Minneeota 56343 .
(612) 935-3556
08/ZO/92 ,
Stodola Well Drillina
15306 Hwy 7 '
Minnetonka, MN 55345
936-2111
Lab #: 17333
,
_ . _ _ _ RBPOAT -O� WATBR ANALYSIS
Our laboratory reporte theae analytieal reeulta, determined on a
sample taken by YOU on 08/18/92 from the following location:
Jim Jensen Homes �
Unique # 479373
2990 Suseex Road
Orono, Mn
Colifor� Bdcteria <1/100 ml
Nitratee NitroQen <1.0 a�g/1
The reaulte of these teeta indicate that thie well ie producinQ water
that meete the Btandarde for F.H.A. , V.A. , or conventional loane.
n ty W e linic, Inc.
Y�_ �
Bill Van Aredale
Brian Blair