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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD � � � � � ,�
f�i€?f1I1@��1i7 Minnesofa Statutes Chapter f03/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
n.
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House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD _
, • ❑ Cable Tool ❑ Driven ❑ Dug
c:�;�::� �.Gl�.'Er3.- �l3.fyW D3:1Er�.: �.�UI�E..°� �I"f. ❑ Auger ffi Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
�U ��,U�`1` t�<<`w Showing property lines,
roads and buildings. DRILLING FLUID_
N �ri?..4�;Fi�.t.z,
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-; -,- -;- -,-
USE O Monitoring ❑ Heating/Cooling
� i � i X �Domestic
�� �-�� ❑ Community PWS ❑ Industry/Commercial
_I_ _J_ _L- -I_
❑ Irrigation ❑ Noncommunit PWS
i i i i Y ❑ Remedial
yy E T ❑ Test Well ❑ Dewatering ❑
i � i i
i i i _� I CASING Drive Shoe? ❑ Yes �lo HOLE DIAM.
VZrn��e
_i_ _ �_ L _i_ I ❑ Steel ❑ Threaded ❑ Welded
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�Plastic O
s
�-1 Mile--i
CASING DIAMETER WEIGHT �
PROPERTY OWNER'S NAME ' in.to �JG ft. �.�'' Ibs./ft. f �1y�.ie .::K.
t:C)�'1jj Vi'�;'� in.to ft. Ibs./R. in.to ft.
Property owner's mailing address if different than well Ixation address indicated above. in.to ft. Ibs./ft. in.to_tt.
���' SCREEN OPEN HOLE
� � � �� ���
c i:�.;r Make �C' �'�'�'�� from ft.to tt.
i�cxic� 7:��?�.e, R'lt�. ..__:�f�
Type :3�.c31P1��'d �J�E:E�. Diam. �. ,�
SIoVGauze �y�,!7�� Length
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Set between �c•�� ft.and ry FITTINGS: � �� 4`'% �� • '
—r�z— —�T:;
STATIC W TER LEVEL
WELL OWNER'S NAME ��-'r ft. E?below ❑ above land surface Date measured �3--}�__�
PUMPING LEVEL(below land surface)
Well owneYs mailing address if ditterent than property owner's address indicated above. tt. after hrs.pumping �-����� <i�-��'g.p.m.
WELL HEAD COMPLETION �,���itc�k.�er
O�Pitless adapter manufacturer Model
❑ Casing Protection L5 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? Q'3'es ❑ No
HARDNESS OF Grout Material ❑ Neat cement O Bentonite ❑ Concrete �'4iigh Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO „
from �'to -%�� ft. �'❑ yds. C�1bags
�.�.�2�� Gx,��� � �;a '��� from to ft. ❑ yds. ❑ bags
from to ft. ❑ yds. ❑ bags
NEARES NOyyjJ SOURCE OF CON�AMINATION t! S.. �, �
��.c��Jf i�:3"K1 �.?r:t"h �iK' '�' � 1 L.�• �I ra� - — feet � �+t.+ � �+� direction `�-'� f�''• ;� type
Well disinfected upon completion? Q Yes ❑ No
CI<;�y F'+�ic;iizsii L�r;.ff.��i f�l 1�'; 7�;:
PUMP �,.._��S-�i��
❑ Not installed Date iRctalled
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:�,3T�Kl (iY�� :i ��.r'1 L!ri..'-F Ma�ufecturer's namq _ .
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Model number � ��"'� HP Volts `�'��'
Length of drop pipe �'%� ft. Capacity 4 i: g.p.m.
Pressure Tank Capaciry ���i� -�`����;I
Type: �'Submersible ❑ L.S.Turbine� ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes CJ�lo
VARIANCE
Was a variance granted from the MDH for this wetl? ❑ Yes q�Jo
WELL CONTRACTOR CERTIFICATION
Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF The information contained in this report is true to the best of my knowledge.
L�C.;�d :;`z;?�;.Lt'� t"�F51. I�RI:�i_IT� t,'t�=., :tl�. �:'il '1.
��g 2 O 1997 � Licensee Busines Name �. Lic.or Reg.No.
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C}SY OF�RONQ AuthonzedRepresentahveS�gnature Dafe
�:i:t:�: tu_x���� �—i�—��
`-, k� rt.: �.
Name ol Oriller Date
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�_ . . � � � `�.� F>> '�a .� ��:✓ � HE-01205-05(Rev.1/95)
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� Jwirc �it� UVater �Linic, J�rtc.
617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556
08/21/1996
Stodola Well Drilling
15306 Hwy 7
Minnetonka MN 55345
938-2111
REPORT OF WATER ANALYSIS
Lab#: 30617
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 08/14/1996 from the following location:
John Vogt
2755 Copper View Dr
Unique Wiell#586469
Coliform Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/I
The results of these tests indicate that this w�ell 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).
,�
� ate Clinic, Inc.
Bill r
Analyical laboratory Cooeulting Fig�oecr
Water Malysis IZca�yents Boila Water Cllemicals
L.ab Certifioation y 027-033-119