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WELL LOCA ION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
Ccunty Name WELL AND BORING RECORD � g�4 �1
� in Minnesota Statutes Chapter f031 �
�� Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
` c�,o iZ� z3 a ,, �, ,, �4s ft io-to-o�
GPS DRILLING METHOD
LOCATION: Latitud �� degrees minutes __ seconds .
Longit degrees minutes seconds i_J Cable Tool n riven 'Dug
-]Auger '�Aotary ❑Jetted
House Number,SVeet N e,City,and Zip Code of Well Location or Fire Number � �
31� ds QCOI�X� 55356 ORILLING FLUID WELL HYDROFRACTURED? f]Yes ,'S�QJo
�T
Shop exact loca ion of w II in section grid with"X". Sketch map of well location. �/$te;' FROM ft.TO ft.
Showing property lines, _ ----
� roads and buildin s USE � r� 9 — ="
N CI�. `� No cosmmuni PWS �E�i ationB�re Hole J�Heating/Cooling
9
, , ,;✓�� L' ; ��Industry/Commercial :•
--'--- ------` �- y� � � �ty � g i Remedial �
��"���'�` '��Community PWS ��Dewatering �
--'-- - '--• ---`- ---`- `-
CASING HOLE DIAM.
�' yy ; i ! ; E� D ive Shoe? ❑Yes ',�No ���
r
__ � J Steel ^'�Threaded ��Welded
'h Miie � Plastic []
- : ; : ; 1 �
: --;-----�-- --� ---:- ,
CASING DIAMETER WEIGHT
S q nt
� �- p _ � in.to��ft. b.lJl Ibs./tt. �_in.to_�t.
1 Mlle _ _ ..r. i_1...a. �� /�� A
in.to __._fl. _ __ _--1bsJft. �_in.to_I��t.
' PROPERTY O ER'S N E/COMPANY NAME in.to ft. IbsJft. in.to ft.
t L CC L � IStL�LiCC1O�I SCREE OPEN HOLE
Property owner' mailing daress if differert than well location address indicated above. Make
��� 8�gt��e��-a�- FROM_ ft. TO____ f[. _�
55� r�o�m Dr TYpe - 1 01.1 Diam
/�,* _.. - --._ — _ -
.. �L�J.� i'A� �'�'.J J'�FJiJ SlotlGauze _�LA� _ __Length___ .��._'�' �� . ._ _ _ �
!
' Set between_1�___ ft.and__l��_ft FITTINGS_�~ ~
STATIC WyAT�ER LEVEL
y " I�?-Ifl-43 ;
- !�_ ft.�below �,__above land surface Date measured_____ ___ _. ,
PUMPING LEVEL(below land surface)
WELL OWNER' NAME/ MPANY NAME ' `
137 _ ft.atter __� hrs.pumping � g.p.m.
WE HEAD COMPLETION �t��er }
Well owner's mai ng addr if different than property owners address indicated above. itless adapter manufacturer________ . _ _ Model_
�Casing Protection _ ._ __ ____ in,above grade
�--1 At-grade(Environmental Wells and Boring ONLY)
GROUTING INFORMATION
Well grouted �es j-�,�No
Grout material ��, �Neat cement ['�.Bentonite �._Concrete �gh Solids Bentonite
from�_to_�_ fl. _ .�_ _�.yds. �ags
from__�_to�,�_ft. ('}$,tjj����� �_'�bags .��
� GEOLOGIC L MAT ALS COLOR HARDNESS OF FROM TO from_ to_____.ft. _ ____.._ I�Yds. �,_,'�bags �n
MATERIAL
NEAREST KNOWN SOURCE OF CONTAMINATION
�� feet --- direction ��'� �' 'ty�e
clay yellow ft 0 18 - - — � — --
. Well disinfected upon completion Yes ❑No ��-'
C� �j�av �ft �� � PUMP
J io-u�-a�3 -��
;J Not installed Date installed_.__.. __ __ �.
�� a�� �ft [fA '1�$ Manufacturer'sname_ �r����.._� ___.--.—
C� 7tJ A
Model number ` HP ���Volts `�
Length of drop pipe ��v ft Capacity _ ___g.p.m.
� Type:� ubmersible �LS.Turbine ',J Reciprocating �`���Jet ❑
� ABAN ONED WELLS
Does property have any not in use and not sealed��ell(s) _j Yes j o
� VARIANCE S
Was a variance granted from the MDH lor this well? ��';Yes � o TN# �`
� WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules.Chapter 4725.
The informatlon contained in this report is true to the bes�of my 4;nowledge.
seasecondsheet,i/needad DonSLodola t�ll �iiling Co�� Il�• G7�72
REMARKS,ELEV ION,S RCE OF DATA,etc.
Licensee Business ame � '.or Reg.No.
i�
� f. '�� Il-I8-03
: - ----- __ ._ __. ---
rize epre entative SignaC�r`e� Date
c�k rwo� It3-1p-03
OCAL COPY 6�6 4 81 Name olDriller �ate
HE-01205-08(Rev.5/02)
IC 140-0020
. . _
wi�vv C i,�"y litl a�"�' C ' ' ; I v�►,ci.
17 13th Ave So � Hopkins, Minnesota 55343 • (6 i 2) 935 - 3556
Ol/05/2004
St ola Well Drilling
3 1 Norih Main
Sr. onifacius MN 55375
9 -2111
REPORT OF WATER ANALYSIS
Lab #: 1151
O Labora[ory reports ihese analytical results, derermined on a sample taken
by LIENT on 12/29/2003 from [he following location:
L. Cramer Const.
3120 Sussex Rd
Orono,Mn
� Unique Well #696481
Coliform Bact� ria <1/100 ml
Nitrates Niirogen <1.0 mg/I
Th results of these t�:sts indicare rhat this well is producing water rhar meets the
sta dards for F.H.A., V.A., or conventional loans. This report is an analysis for
co! rm and nitrate only and does not include analysis of Lead and orher
ico aminants. (Unless as specified by client).
C'ty Water Clinic, Inc.
�ill sdale
Lab Certification#027-053-119