HomeMy WebLinkAboutwell info WEI,L LOCA ON MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
. CountyName WELL AND BORING RECORD � g 0 5 7 3
�E-'�T��-'��1� Minnesota Statutes Chapter 103/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) . Date Work Completed
Urona 117 �� (34 4 tu� ` " 3-6-�7
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House Number,Street Name,City,and Zi Code of Well Location or Fire Number DRILLING METHOD
,L f�'jr (.,ClL1Il�X"���3,.�2 �}11V� �GSt �2"OI1C��T'��. ❑ CableTool ❑ Driven ❑ Dug
❑ Auger �Rotary ❑ Jetted
Show exact location of well in section grid with_°X". ���;� Sketch map of well location. ❑
Showing property lines,
roads and buildings. DRILLING FLUID
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USE ❑ Monitoring ❑ Heating/Cooling
� i i i Domestic ❑ Communi PWS
� �Irrigation ty ❑ Industry/Commercial
-�- -�- -�- -�-
i i i i _ . ❑ Noncommunity PWS ❑ Remedial
yy E '��" ❑ Test Well
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� � � i " y✓I ❑ Dewatering ❑ `
-r i i _r � �^��---.-.- '--" CASING Drive Shoe? ❑ Ves ❑)(p HOLE DIAM.
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_� i _L_ _i_ I . � ❑ Steel O Threaded ❑Welded
' � ' � 1 C�Plastic ❑
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�IMlle-� � -
!�- .-.-� j CASINGDIAMETER f. WEIGHT � ,
PROPERTY OWNER'S NAME �� in.to 1 �Jft. � ' � Ibs./ft. � in.io�t _�R
rl`UI2y' �:1Ci@Tl E:t3�t�tc�It�7 in.to ft. Ibs./ft. in.to R.
Property owner's mailing address if ditterent than well location address indicated above. in.to ft. Ibs./fl. in.to ft.
��I�1C� E!@Y�StZI.�'� L�TI� SCREEN OPENHOLE
��.�I[[�11't�l��I'1. �r�Q� Make a1 Ut121�(JTl from ft.to fl.
TYPB �t�3.I�11.E�a G.i ��C.-'t��, Diam.
SIoVGauze ]_(;s�i �e� length '
Set between �j�_ ft.and 1�< ft. FITTINGS: i� h. .'�.U tt fa'� ..t>. ��:
STATIC WATER LEVEL
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WELL OWNER'S NAME t�4' n. O�'below � above land surface Date measured �—b--�f �
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. ��F t` ` ft. after � hrs.pumping ��:"���l Ig.p.m.
WELL HEAD COMPLETION h � � �-
t�.,1 a�E.4�':t'�.�I
C��Pitless adapter manufacturer Model
❑ Casing Protection �A 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? �Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete Q�iigh Solids Bentonite
MATERIAL from �> to ��%ft. .% ❑ yds. � bags
�C��.? �.'C�31.� �L:.ii�jS. 3 ;� ' � .r`, ; from to ft. ❑ yds. ❑ bags
from to it. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
�1..��T BYGIWXl � � `." � !� � , feet direction �-rype
Well disinfected upon completion? f3�Yes ❑ Na
C..�c'1� CiT��� �.rJ .f£� r i t f! PUMP
❑ Not installed Date installed --d �
`�i�I1C��Clc"1�7 GZ'��l � � '�(' � � 'tj�nutacturer'sname n�'r;��u _�,�
Model number �.���aGC v L�Y 7 HP ��'•'s Volts �.:�;
Length of drop pipe_ � �� ft. apacity�`.�(�g.p.m.
�'it:'.fi. ��'7illC'1. �L��.O�' G`� �u ���- { ��%�% lpressureTankCapacity �--'ti -'�f�'�
Type: �.Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Dces property have any not in use and not sealed well(s)? ❑ Yes C};No
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes dKNo
WELL CONTRACTOR CERTIFICATION
Use a second sheet,il needed This well was dril�ed 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 ot my knowledge.
L�{>N ...•lt.7l3i,:�,i-i 44't.Ll� 1)R:i t.�I.T.�.0 :�i: � I�3�:
Licen�pe Business/Vame Lic.or Reg.No.
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�ufhorized Representafive Signature' Date
(:I�L2<"k I�'_•c?cY"e ._ -�--: !
Name ol Dnller Date
._ :� � �Pi � �,
HE-01205-OS(Rev.1/95)
.
f Ju�in �ity 1/Vater ��inic, J�rcc.
617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556
03J12/1997
Stodola Well Drilling
15306 Hwy 7
Minnetonka MN 55345
938-2111
REPORT OF WATER ANALYSIS
Lab#: 32171
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 03/06/1997 from the following location:
Tony Eiden
275b Countryside Dr W
Orono,Mn
Unique 1Mell#580573
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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�\ ity ater Clinic, Inc.
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Bill Va Arsdale
�,�o,i u�,�y c�nma�
w,ter au„ly�ie xeagero soiler w.ur cbomioau
Lab Cortif ioation M 027-033-119