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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELL AND BORING RECORD 6 4 9 2 3 9
Henne�i n Minnesota Statutes Chapter 103!
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
n.
OtOnO 118 Z �� �� '�• ' - -
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
��� ❑ Cable Tool ❑ Driven CI Dug
175 Cr S a • ❑ Auger �1 Rotary ❑ Jened
Show exact location ot well in section grid with"X". 5�3 S b SkelShowaPq�dipert lainleg, �
, roads;�nd bui mQs. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �q�JO
N
, , , , QLi�Ck— @1 FROM_ n.io n.
-,- -;- -;- -,-
USE ❑ Monitoring ❑ Heating/Cooling
i i i � � . �7 Domestic ❑ Communit PWS
-�- -a- -�- -�- i `fJ Irrigation Y ❑ Industry/Commercial
i i i i ❑ Noncommunity PWS ❑ Remedial
yy E T � - ❑ Environ.Bore Hole ❑ Dewatering ❑
i i i i I
-r -�- -r- -r .
� i i i ��2M e � "�,,. CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
i i i � ❑ Steel ❑ Threaded ❑ Welded
-� - �- -� - -� 1 ;��. �] Plastic Xl �llle
S �'
�-1 Mile--i
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME 1� in.�o_��.�ft. __�� Ibs./ft. ���(�_�
RV�r H�Q��$ — in.to fl. -_--- --Ibs./ft. �in.toi�_'tlft.
Property owner's mailing address if different than well location address indicated above. in.to_____fl. ________ Ibs./ft. in.to R �
SCREEN OPEN HOLE
Make_ _T���_.__ from ft.lo__, ft.
Type_�`�= Diam. �
SIoUGauze _ Length A t _____.__
Set between 1 '7�_'�R.and��__ft. FITTINGS: 7�.�7n w n..�.+ 1 ade�
STATIC WATER LEVEL K� cke�
WELL OWNER'S NAME _�_� ft.�below ❑ above land surface Date measured_n��_a�n�
PUMPING LEVEL(below land surface)
� Well owner's mailing address if different than property owner's address indicated above. _}'��ft. aRer__,7 _ hrs.pumping� g.p.m. -
i
WELL HEAD COMPLETION
�1 Pitless adapter manufacturer r���`�� Model
❑ Casing Protection__ _ __.__._ � 12 in.above grade
❑ At-grede(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? LXYes ❑ No
HARDNESS OF Grout Material C] Neat cement ❑ Bentonite ❑ Concrete High Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
from�_to _�__ft. _ _ _ ❑ yds.,�bags
from_ 7A tot �7�.___tt. �����$S yds. ❑ bags
�v iT
� � from to R. ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION
__,_g_�___,feet ___�______direction �ranr�type
� �
Well disinfected upon completion? � Yes ❑ No
PUMP
❑ Notinstalled Dateinstalled . +����+�oo _
Manufacturer's name __ ._�''$���__ . . _ _ _ _._ --
Model number _ _ _ __ _.__ HP _�*�_ Volts__�_�____
Lengthofdroppipe ____.�,_2_�_ ._ ___ tt. Capacity _g.p.m.
Type: T�Submersible I.-1 LS.Turbine ❑ Redprocating ❑ Jet Cl _____
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes � No
VARIANCE
Was a variance granted from the MDH tor ihis well? ❑ Yes �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.
The information contained in this repoR is irue to the best of my knowledge.
REMARKS,ELEVATION,SOURCE OF DATA,etc.
DOAi STODOLA idELL DRILLYNG C0. , INC.
Licensee Business Name-� . Lic.or Reg.No.
----�- �„ 2 7 i 7 2
/- - _:,�
u onze� ta ve�i nature �Date
Duane Mathews 8-10-00
6 4 9 2 3 9 Name ol Driller Date
LOCAL COPY HE-01205-07(Rev.2/99)
rw� c�-y w�-� c � � � .r�,�
617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556
OS/15/2000
Stodola Well Drilling
3841 North Main
St. Bonifacius MN 55375
938-21 1 1
REPORT OF WATER ANALYSI5
Lab #: 39684
Our Laboratory reports these analyrical results, derermined on a sample taken
by CLIENT on OS/10/2000 from the following location:
RVC Homes
175 Crystal Creek Rd
Orono,Mn
Unique Well #649239
Coli form eacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/I
The results of these tests indicate that this well is producing water that meets the
standarcls for F.N.A., V.A., or conventional loans. This report is an analysis for
coliform and nitrate only and does not include analysis of Lead and oiher
coniaminants. (Unless as specified by client).
T � Water Clinic, Inc.
Bill Va
Malyical laboratory Consulting ingineer
Water Malysis Reagen�s L3oiler Waler Chemicals
Lab Certification#027-053-119