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W LL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
�o tyName WELL AND BORING RECORD �A .� .� � _
� �
Minnesota Statutes Chapter 1031 �: I � � � � <;+
To nship Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
n.
x v. �i.
Ho se Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLWG METHOD '
l� CableTool ;�7 Driven ❑ Dug
� . 17 Auger ,�rRotary ❑ Jetted �`,
,; Sh w exact iocation of well in section grid wi "X". Sketch map of well location. �`-'. _ ::
� Showing property lines, - � �� - ��
roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? [�YES ,�10
N �� Wa t e r .FROM ft.to R. �
_i i i i_ � � ,�.1, ---- —
i ___ _i_ _i �,,.
� 9 USE ❑ Monitoring ❑ Heating/Cooling
i i i i C�omestic
❑ Community PWS ❑ Indust /Commercial
i � i i i f; Irrigation ❑ Noncommunity PWS ❑ Remed al
I ' i I E \ � �.°t^' ❑ Environ.Bore Hole ❑ Dewatering ❑
T \ 1_.
i _, -r _r ,/ZMQ CASING DriveShoe? es ❑ No HOLEDIAM.
_i i _L_ _i_ � . �' .pl!Steel r�Threaded — ❑ Welded
� - �- � � Y 1 Cl Plastic ❑
s
�—,Mae—� T-.
' CASING DIAMETER { WEIGHT t
PR PERTY OWNER'S NAME 4 in.to_ I`�Oft, _ 2 s Di _Ibs./n. $ in.to �On.
Tony Fiden Company _��.to- - h. ----------�bs.�h. �,� ,��$h.
Pro rty owner's mailing address it difterent than well location address indicated above. _ _ - .._ in.to_____ft. _____ Ibs./ft. in.to ft. ?�
4100 Berkshire Lane SCREEq������n__ OPENHOLE
�-�� i"l����t h� 5711 ��H'i V Make'J_ --p �—_.— t from_. ft.to ft. ,�`
Type St_aiFlle..gg $�e�i Diam. -_
SIoVGauze_ __ �_D�_Q__ _.,_Length_.��_.�_. �
Set between _____��,�_ft.and__�_��ft. FITTINGS: 7z��s jl1Q„_o_��y�
s r
STATIC WATER LEVEL Y
WE L OWNER'S NAME _____��____fl. C�ibelow ❑ above land surface Date measured A��'Z
PUMPING LEVEL(below land surface)
Well wner's mailing address if different than property owner's address indicated above. _.���_.,_.___ft. after ��hrs.pumping_�S g.p.m.
WELL HEAD COMPLETION
�Pitless adapter manufacturer��y�st.�_��_�`_�� Model
Casing Protection. _ CYI2 in.above grade
.�
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? �(Yes f i No
G OLOGICA�MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ Bentonite ❑ Concrete �'Fiigh Solids Bernonite
MATERIAL
from_._ �to_'�_ft. _"�__ ❑ yds. f�bags
lay browfl soft 0 l.8 from—��o�� K �a��r� ���� bags
NEAREST KNOWN SOURCE OF CONTAMINAT� -1 ;
I�,y �r��7 ��it y0 �Q !�__ feet _---� _ _direction � !.�-� bPe .
--��-- ,
Well disin(ected upon completion9 f�(Yes �; No
SLZ� bCONT� SOLL 7O 1�O PUMP
CI Not installed Date installed 7�2 t�'OZ
Ia r� �OL� 11� �L� Manufacturer'snameA�r�aotor
` t e� A Modelnumber___.--. .------ -- ---_---- HP �..�.__ Volts__.�_�a__ �-
�� an� bro� �d�t 1G5 �4C7 Lengthofdroppipe .. ____��____ ft. Capacity ___________g.p.m. r
Type: ��� Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
� ABANDONED WELLS
Does property have any not in use and not sealed well(s)? C Yes L�?�Jo
i�
VARIANCE
Was a variance granted from the MDH for this well? �� Yes No TN#
WELL CONTRACTOR CERTIFICATION
.�.'�Use a second sheef,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. -
REM RKS,ELEVATION,SOURCE OF DATA,etc. The informUtion contained in this report is true to the best of my knowledge.
s`''01 t} `L 5 �°"`'j I�e�-r�-�-E 17 2
c ine ._ _. Lic. �j.�Jo. •
._....-'I /
C17-Y OF U�tpNU �� _. _ �__.-- 14-21-02—
Authon ed epr�sentatNe� ignature� Date
Chuck Moore 9-24-02
Name ol Driller Date X
LOCAL COPY � � 7 8 7 3 HE-01205-07(Rev.2/99)
IC#14 -0020
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rw� c�y w�-� c � � , r�.
617 13th Ave So � Hopkins, Minnesota 55343 � r (612) 935 - 3556
09/26/2002
Stodola Well Drilling
3841 North Main
St. Bonifacius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab #: 10003
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 09/24/2002 from the following locacion:
Tony Eiden
3160 Sussex Rd
Orono,Mn
Unique Well #677873
Coliform Bacreria <1/100 ml
Nitrates Nitrogen <1.0 mg/1
The results of these rests indicate that this well is producing water 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 speci fied by client).
in City Water Ginic, Inc.
�eill A sdale
.
Lab Cettification#027-053-I 19