HomeMy WebLinkAboutwell info WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH
MINNESOTA UNIQUE WELL NO.
County Name WELL RECORD
561365
Minnesota Statutes Chapter 1031
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Dug
❑ Auger ❑ Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing property lines,
N roads and buildings. DRILLING FLUID
1 i r
i I W t .USE ❑ Heating/Cooling
_ �_ �_ X 17 Domestic ❑ Monitoring
W i I E ❑ Irrigation ❑ Public ❑ Industry/Commercial
' T [ITest Well ❑ Dewatering ❑ Remedial
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r-mi. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
❑ Steel ❑ Threaded ❑ Welded
r 1
I 1 mitr j L7 Plastic ❑
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME n.to ft. lbs./ft. n:t5 ft.
X2"7'?' GT?2(il"4i in.to ft. —_-__--- lbs./ft. _m to ft.
Mailing address if different than property address indicated above. in.to ft. lbs./ft. in.to ft.
SCREEN OPEN HOLE
Make_ ,` a' u'`- '(Dn from ft.to ft.
Type _ inles�> Sf-e''_j Diam.
Slot/Gauze i Length +' t
r
Set between _ft.and 1; _ ft. FITTINGS:
STATIC WATER LEVEL
GEOLOGICAL MATERIALS COLOR HARDNESS OF
RDNESSOF FROM TO ft. Ll below ❑ above land surface Date measured
MATERIALPUMPING LEVEL(below land surface)
ft. after hrs.pumping g.p.m.
WELL HEAD COMPLETION
L7 Pitless adapter manufacturer - Model
❑ Casing Protection __ El 12 in.above grade
GROUTING INFORMATION
Well grouted? O.Yes ❑ No
i Grout Material ❑ Neat cement q-
,Bentonite
from to ft. ❑ yds-® bags
from to ft. _ ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
NEAREST KNOW_ N SOURCE OF CONTAMINATION _
feet /G IQ direction e7'iC type
Well disinfected upon completion? Q Yes ❑ No
PUMP
❑ Not installed Date installed
Manufacturer's name
Model number T T_ HP Volts
Length of drop pipe i ft. Capacity __g.p.m.
Pressure Tank Capacity ',� 'i': i`, _
Type: ❑ Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes O No
WELL CONTRACTOR CERTIFICATION
This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Use a second sheet,if needed D00 :?'r1(-V Td, IYEH.a DRILLING CO. f -
REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee BusinessNameLic.or Reg.No.
Authorized Rhe-prresentative Signature Date
Name of Driller Date
LOCAL COPY 561365 HE-01205-04(Rev.5/92)
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Twin City Water Clink, Inc.
61713th Ave So Hopkins,Minnesota 55343 a (612)935-3556
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08/05/1995
Stodola Well Drilling
15306 Hwy 7
Minnetonka MN 55345
938-2111
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REPORT OF WATM ANALYSIS
Lab t 26853
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Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 08/03/1995 from the following location:
Barry Knight
425 Tonkawn Rd
Long Lake,Mn
Unique Miall g 561365
Coliform Bacteria <1/100 mi
Nitrates Nitrogen 4.0 m
09 9/1
The results of these tests 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 specified by client).
W ter Clinic, Inc.
Bil
Ansbiod
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wawAnobi.a.
Lb CaAfiodion/027-053-119
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