HomeMy WebLinkAboutWell info WELL�OCA�IQpJ MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
� CountyName ln WELL AND BORING RECORD , � � 4 31
�� Minnesota Statutes Chapter f03!
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
-7 ry ) y ft. t'
�C7�ZG ��I 6.3 ��La. �lF���F!I�i X G�t:f �"JV"'��
� House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
�r _,+. ❑ Cable Tool O Driven ❑ Dug
L��:t CiC�17I2� .,3C� �. �d ���� ��• �'=�'f' ❑ Auger E5 Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
Showing propeRy lines,
roads and buildings. DRILLING FLUID
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J�,/� USE O Monitonng ❑ Heating/Cooling
i i i � 1, � [?:Domestic ❑ Community PWS ❑ Industry/Commercial
_i_ _�_ _�_ _i_ F G. M1. � ❑ Irngation
w � � � � E X w�� . �'� ❑ Test Well � Noncommunity PWS ❑ Remedial
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`� ❑ Dewatering ❑
i i i -� ,�'M,ie � �'� CASING Drive Shoe? O Yes �o HOLE DIAM.
_� i _L_ _�_ � � ❑ Steel ❑ Threaded ❑ Welded
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!� d{Plastic ❑
s
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CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME a in.ro �t''� ft. Ibs./n. f ���o `�,
Tc�rty �i.c+en C���n��
in.to ft. Ibs.Rt. �,�.�p���.
Property owners mailing address if different than well location address indicated above. in.to ft. Ibs./R. _in.to_fl.
SCREEN___���� OPEN HOLE
Make from ft.to ft.
Type � £`S'-�'' �P�1 Diam. �.n
SIoVGauze �t}/��J Length t�{
Setbetween ` �� R.and ��—k. FITTINGS: G� �i ��.�
STATIC W/�TER LEVEL ��,y��y
WELL OWNER'S NAME �� tt. D�betow ❑ above land surface Date measured j� �
PUMPING LEVEL(below land surface)
Welt owner's mailing address if ditterent than property owner's address indicated above. R. after hrs.pumping g.p.m.
WELL HEAD COMPLETION ��i����,
Q�itless adapter manufacturer Model
❑ Casing Protection q�2 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? ❑�.f'es ❑ No
HARDNESS OF Grout Material ❑ Neat cement Bentonite ❑ Concrete ❑ High Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � �
from to �%U ft. � ❑ yds. Cp�bags
t t from to ft. ❑ ds. ❑ ba s
7'ap Sc�i�.,lCl�-�y Cs��' a�. � ��!t_•' Y 9
from to ft. ❑ yds. ❑ bags
NEAR j KNOWN SOURCE OF CONTAMINATION . r '
�lay k7��dV@Z Dc�}C Gt3.E" :� �t.+�3 ��4}� i teet ����� � direction �E � 4 tYPe
Well disinfected upon completion? LY Yes ❑ No
`-�.�ci21C'f f''li1E? �'C3VuTi :.i ��l% L(.-(�T
PUMP C
❑ Not installed Date iostalletl �_�_�v ._ �
�311Gt��. �j� 4 L�)�f ���� Manufacturer's name __
Modelnumber a HP �� Volts ��f!
Length of drop pipe �u�i R. Capacity '�� g.p.m.
Pressure Tank Capacity (�i=�'y�ZL")j'1 �(��;d�
Type: C�y"^ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS /
Dces property have any not in use and not sealed well(s)? ❑ Yes CJ 1V6
VARIANCE
�
Was a variance granted from the MDH for this well? ❑ Yes �No
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 DATA,etc. The information contained in this report is true to the best of my knowledge.
� :`��i�}� �°��.1r ��.� ��).� .LIV�.. G 1�J i
Licensee Business Name Lic.or Reg.No.
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Authorized Representative Signature Date
�:t 1t1�'r� hk:�;�4
�'` (''� t � � Name ol Driller Date �
�.-� • .. � t-"�'" °"F "' " L_i' �� � HE-01205-05(Rev.t/95) �
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� Jwin �itc� UVa�er ��ircic, J�rtc.
617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556
06/06!1996
Stodola Well Drilling
15306 Hwy 7
Minnetonka MN 55345
938-2111
REPORT OF WATER ANALYSIS
Lab#: 29800
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 05/29/1996 from the following location:
Tony Eiden
2715 Countryside Dr W
Orono,Mn
Unique Well#580431
Coliform Bacteria <1/100 ml
Nitrates Nitrogen " <1.0 mg/I
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).
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i ater Clinic, Inc.
BiU� �
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Analyial I�boraWry Comultu�g Nsgineer
W+ter AnalYeu Re+geNa Boilor Watm Chemicals
l.ab Certdication#Q27-033-119