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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELL AND BORING RECORD 6 7 3 H 7 2
He nne p i n Minnesota Statutes Chapter103/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
tt.
Orono 118 23 33 �,, �,. �,. 193 2-8-02
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
165 CTystal Cceek Rd Or��Q SS3>V �] CableTool riven ❑ Dug
) �:"l Auger Rotary ❑ Jetted
Show exact location of well in section grid with"X". Sketch map of ation. f;
Showing pr p �-� lines,
roads� bu dings. DRILLW FWID WELLHYDROFRACTURED7 ��YES O
N � entonite
� � � � FROM n.co n.
,- -;- -,-- -,
� � USE ❑ Monitoring ❑ Heating/Cooling
i i i i � ` �Domestic ❑ Communi PWS
-i- -�_ _�_ _i_ �— f] Irrigation h' ❑ Industry/Commercial
i � i i �� ❑ Noncommunity PWS ❑ Remedial
yy E T 1:7 Environ.Bore Hole
i � � i ❑ Dewatering ❑
� i i � �2IM e j CASING Drive Shoe? ❑ Yes No HOLE DIAM.
' - '- -i- -'- y� ❑ teel ❑ Threaded ❑ Welded
-� , � � 1
Plastic ❑
S 1-.
�—,M�a� �
�-�' CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME �in.to��ft. Z.n� Ibs./ft. �in.to�Q
LC�Ae�OOd DeVElO ��GTiC —_ in.to _ fl. Ibs./ft. �in.to��
Property owner's mailing address if different than well location address indicated above. —_--_._-_in.to _ fl. __Ibs./ft. in.to____ft.
2354 W l�ay��$ Blvd �D SCREEN OPENHOLE
Long LBke, 121� 5�3 S Q Make $t ee 1 from ft.to fl.
TYPe--- .—�}�_ Diam. �_��
SIOVGauze_ _���V �� Length
Setbetween 10,1 ft.and 17�ft. FITTINGS:
STATIC WApTER LEVEL .��Q`�
WELL OWNER'S NAME 9 v ft.�elow CJ above land surface Date measured�—�2
PUMPING LEVEL(below land surface)j
Well owner's mailing address if different than property owner's address indicated above. ���_ft. after_ i�S _hrs.pumping_�Q g.p.m.
�LL HEAD COMPLETION C EWS C e C — —
Pitless adapter manufacturer Model
❑ Casing Pwtedion_ ___.._�12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING WFORMATJQN
Well grouted?=19 Yes ❑ No
HARDNESS OF Grout Material ❑ Neat cement p Bentonite ❑ Concrete�Hi h Solids Bentonite
GEOLOGICAL MATERIALS COIOR MATERIAL FROM TO �/
from_. 0 to 3O.n. Z• ❑ yds.L9 bags
e1a vellov �edin� 0 3 from__���0 18� n. Q�t��_���.�� bags
Y l from to _ ft ❑ yds. ❑ bags
` Q /� NEAR 1dN SOURCE OF CONTA��y/11NA/T/�q�y �"'�
clay gray �Di� 3Q 7 ---� feet G.�V�-_�f directio� � ! �' type
Well disinfected upon completion? �Yes ❑ No
aand gray sof t 90 I� PUMP
3-�2-02
�{ S ❑ Not installed Date installed
clay gray �ed3um 11� a J Manufacturer'sname Aermotor
�raQel ��r SOrt lsa 1 C � Modelnumber _ *�� __ HP � Volts��Q
1 1 J
Length of drop pipe __. I __ ft. Capacity g.p.m.
sand bcown ��l C 155 17 Type l:: Submersible ❑ LS Turbine C7 Reciprocatmg ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes f�No
VARIANCE
Was a variance granted from the MDH for this well? (l Yes �[�f.No TN#_
!
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 ihis report is true to the best of my knowledge.
I3on Stodels We�l Dci_1_liB�o- - Inc. 2 172
Li nsee Bu ' ss Na � �,"� ic.or Re�
'� 3-22-02
, �,. ;
Authorized Rep entative Signature Date
Chuck Moore 2-�-02
� � � Name ol Driller Date�
LOCAL COPY 6 7 3 8 7 2
HE-01205-07(Rev.2/99)
IC#140-0020
� . .
rw�, c�-y w�-� c � � , 1�,�.
617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556
02/13/2002
Stodola Wel! Drilling
3841 North Main
St. Bonifacius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab #: 134
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 02/1 1/2002 from the following location:
Lakewood Devolpment
165 Crystal Creek Rd
Orono,Mn
Unique Well #673872
Coliform Bacteria <1/100 ml
Nitrates Nirrogen <1.0 mg/I
The results of these tests indicate that this well is producing water that meets ihe
standards for F.H.A., V.A., or conventional loans. This report is an analysis for
coliform and nitrare only and does not include analysis of Lead and other
conraminants. (Unless as specified by clienr).
� � City Water Clinic, Inc.
Bil�' �2l le
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Lab Certification#1127-053-I 19