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HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. lo����,Jaine �P�n��,� I j WELL AND BORING RECORD 5 g 110 0 Minnesota Statutes Chapter 103/ _ Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed . n Urc>nr. i i ; 2� ; �; ,. ,. ,. 1 "� �—?.(,—9 8 � House Number,Street Name,Ciry,and Zip Code ot Well Location or Fire Number DRILLING METHOD �7 Cable Tool Driven ❑ Dug i(; � � �'.�'USS�X RC:�C1 U�OTIC3� �Tl. ;�yg�,.. � Rotary ❑ Jetted Show exact location of well in section grid with"X". Sketch map of well location. "; ��f'7 __ __ Showing property lines, .�—�- _��E Z /� roads and buildings. �. DEi}F..�C1RlG FtUID �2E•I�l Lf�;tA a�.r� - . . N � iJ " .. I I I I ' . . . . .. � . _I_ _-_ ___ _I_ . . .. ... � - USE � � ❑ Monitoring � Heating/Coo6ng i i i i . � � . �].DoF1'lestic ❑ Communit PWS ��- � ���O��Irrigation Y ❑ Indusiry/Commercial � , J � i ❑ NoncommuniryPWS ❑ Remedial .. �� W E �r�-�-'"' r i�'Tesf Welf � . i i i � �X - ❑ Dewatering ❑ _ i , � i ,�'M e _ - GASit�� y Drive Shoe? ❑ Yes ❑ No HOLE DIAM. - _� i L _i � �� � .�d��Steel -� ❑ Threaded � ❑ Welded . i - i- i i ,p.Plast�c � g - . . . . - .. :z.��, .�0.���: ^, . _ . ' �—iM�le—� .. ��. .... . ' ".�' ', _ �'' ' , r�., CkSING DIAMETER: : WEIGHT . �� ; PROPERTY OWroER'S NAME � in.to__' c i ft IbSJR. in.to�{'ft. . .: . - . .. � ' . � . � 's t_:t��r `Ei.c?en `Car�p�kny --- ---��.�o =—" - --= ' : -�b5.m �� to n. . � � � t Property owner's mailing address if ditter�nt than w811 loca4ion address indicated above. in.to tt. . IbsJft.� � f� Jrtf to'����-�tr: ' � � � SCREEN_ OPEN HOLE �. � � �� �� - ��.1���.::k"i I.�`� �.{��1� _ '. .g"Make T.,.,l,.,.�..,r, from ft.to ft. �`1�T'+iG1.t��i y �t�: `"'�3°r 4�3 �`` Type Diam. SIoUGauze�;f 1 i l_ � � Length �~ �j � _ � � Set between � ��7 fl.and � ri. FITTINGS: L�� X 8���j �+��.�� STA'�JC W�TER LEVEL , �; WELL OWNER'S NAME ��' ft. �below ❑ above land surface Date measured �—!�'"'� �. � �� � � ��<. � �... '. � �� PUMPING LEVEL(below land surface) ..,G t3 i r Well owner's mailin§�2ddress itdifferent ihan property owner's address indicated above.� � � `'�"'� tt. after___ _hrs.pumping �� ' g.p.m. _. � �- -� � WELL HEAD COMPLETION � : � � � �7 Pltless adapter manufacturer �ha..�L E:lh���.l t�f'Y Model � �� � � ��'Casing Protection_ �___ � 12 in.above grade - � . . - . � � . .� � At-grade(Enviio�mental Wells and Boringg ONLY) - �� � - . �� �:� GROUTWG INFORMAFION � � � � � ' Well grouted? tj,; Yes �0�No " . - � �� HARflNESS OF Grout Material�'.�Neat cement ❑ Bentonite�.��Ct Concrete High Solids Bentonite C'iEOLOGICAL MATERIALS CQtOR FROM TO ., � ' MATERIAL trom . �i to j��' tt � O yds.�7 bags frorrG_�to fl ❑ yds. ❑ bags , ' �, l.a,�. �'.'y. �,;.; ".� L�.l'_�=J±ti�,�, ..� ..�"'.i� , , .. t:.` :.:..� �-7{„:' ': - '... �..;- �from � ^t9 '� n. � ❑ yds. ❑ bags r � - � - -� N�RREST KNOWN50URCE OF GQNTAMINATION � w^ „� ��r �G�i T I :tit". � �i,. V E�� �j�p^�,<•ll4 � F t T�l,£ .t —� � feet _ �,r� �J'f duect�on -•�f/ c ryPe ,.-.. ..�. , _�;.�. . ..: ...:.:.. -�,: ,.. ,. •���.:.Well disinfected�uPon cor�npletion? ,$;.Ves .[7 No.:� .: ..:.- . `4,�"'.�'�' - Cz.'--..� t;i i I'.1 y,. PUMP� � . � . . ...... - � . �.. � . ., ..�,.. , . . . . -. �..� :.�� �� , . � :,�,. . .✓ �,. ;�� , , . �� �� f� tJot iqstalletl : -..Dete inst111ed..._� ���_,.a.. -���Ci�� . .'L � ,;,� ��' :, � ,� � � �� ManufactUre�snamE __ ____ C.c�`=i 1�: ''� :� .-. , .. , ��. . . . ^ : ; . .. �' _ �'. ��Model number __����J� _ FIP_�,__r_,,,Votts., ,,,�� ' ., ... , . :. . . . . _e:_ :, 3 _ . ,.-, . Length of diop pipe__ _� h.` Capaaty �U g.p.m.., ': , .+ � _ -+_... - , •. :; .� i=T1�: �� Y.'+;T:,.:b:`T��� .:..� �c;�.;-. . � ��' .�`�PressureTankCapacity _�°�$l�' �. , .�.. ,_ . . ��r .. �,�. . '7ype p Submersible �7 L.3,Turb�ne' C1 Reciprocaung ❑ Jef 'p__ , . � . j , ..�: . . . . . . . .' ._ �.�: . , c�. �-��ABANDONED WELLS � �.� ��. �.. � � �. . DaQs propeAy have arty not in use and not sealed welF(s)� C Yes ,�7 No, h j� . . . ��VARIANCE � . : `"� Was a variance granted from the MDH fQnthis well?, ❑ Yes 'p No i=8i � ' WELL CONTRACTOR CERTIFICATION� . � � � � Use a second sheet,il needed ' This well was drilled under my supervision and in accordance with Minnesota Rules,Chapfer 4725.. REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to the best of my knowledge. Di�l� ��`C1I3ULA WEl',L �RILLIiVG CG. , INC. Licensee Business Name Lic.or Reg.No. ��...; i ,�,�,�i"��� � F � � ��7� ��%e,,,�. ,-�. ����;�-7--�8 � Aufhonzed Represent live Signature Date � L'�'lL1C� �C�CI.CE; �'-��r—�/��3 i Name olOriller Dafe ` ` " � -LOCAL COPY 5 9110 0 HE-0,Za�S,��.„�5> „ � �- - �w�� c��� �a�� c���, .�,�. F 61713th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556 02/27H998 stodaa weu a;u�ng 15308 Hwy 7 Minnetonka MN 55345 938-2111 REFORT OF WATER ANALY�IS l.ab*: 34507 Our Laboratory reports these analytical results, detert�nined on a sample taken by CUENT on 02/23✓1998 from the f�lowing location: 3011 Sussex Rd. Orono�Mn Unique 1Ms11�691100 , Coliform Bacteria <1/100 ml Nitrates Nitrogen <1.0 mg/I The results of these tests indicate that this w�ell is producing w�ter that meets the standards for F.H.A., V.A., or conventional loans. This report is an analysis for coliform and nitrate only and does not include analysis of Lead and other contaminants. (Unless as specified by dient). ater Clinic, Inc. Biil n a�t i.�.c�r c,�,�;�� wa«a�ay.;.x�s �w.eer ce�.r Lb Catd'wNiou!027-053-119