HomeMy WebLinkAboutwell info � �
WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName ��,�ne�,�ri WELL AND BORING RECORD 5 ��; �j �j l
Minnesota Statutes Chapter 103/
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) � Date Work Completed
fl.
���';'�r�;� I 1 "t �;:.. 1.�� � �;_'; o �r' �_c —
��, �, �. -
House Number,Street Name,City,and Zip Code o1f Well Location or Fire Number DRILLING METHOD
�:��":; DE?f�Y' �Zl,ij'! �j"r41.11 (,I�L��I��r �1 2. `_.�. :rif> ❑ CableTool ❑ Driven ❑ Dug
❑ Auger C�SRotary O Jetted
Show exact location of well in section grid wit "X;',�� �J yJ Sketch map of well location. ❑
c Showing property lines,
�'Toads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ❑NO
N
���� BEJ'li.�.��Il� : .. FAOM n.to h.
-�- -�- -�_ -�- x �' USE ❑ Monitoring ❑ Heating/Cooling
i i i � C]xDomestic ❑ Communit PWS
_i_ _�_ _�_ _i_ ❑ Irrigation y ❑ Industry/Commercial
i i i i ❑ Noncommunity PWS ❑ Remedial
W I i I 1 E� ❑ Test Well ❑ Dewatering ❑
i i i r ,/ZMie CASING Drive Shoe? ❑ Yes o HOLE DIAM.
_i i � _�_ � ❑ Steel ❑ Threaded ❑ Welded
i - i- -i - i
C37'Plastic ❑
s
�-1 Mile�
CASING DIAMETER WEIGHT
i
PROPERTY OWNER'S NAME � in.to � � ft. � '� Ibs./ft. �� in.io `6ft.
�f,._-'t�-'I_ [-iT'.:�2i��.:"r`, �7.:tiit�3c1T���' in.to n. �bs./n. ��irf:�to�—�'�ft. '
Property owner's mailing address if different than well location address indicated above. in.to ft. Ibs./ft. in.to ft.
SCREEN -r.1,.........�. OPEN HOLE
�:.TI7TS�u\ST�-
Make from ft.to ft.
Type -��'t�'.' {.�. �'tC..''LZ Diam. `
SIoUGauze • } } �p�" �Length
Set between � /7 � ft.and��ft. FITTINGS !.n � 5O� S+.'; �
STATIC WATER LEVEL
t�' t �t_.'.
WELL OWNER'S NAME `_1 ft.2� below ❑ above land surface Date measured _;{i—�
PUMPING LEVEL(below la�d surface)
Well owner's mailing address if different than property owner's address indicated above. � i.i F ft. after ! . �� hrs.pumping c'.^ c i 1 1"�g.p.m.
v�tFLL HEAD COMPLETION
�x G�1�2�.�4i'�i'i:E:Z
Li Pitless adapter manufacturer 'Model
❑ Casing Protection �12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? C��Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement ❑ eentonite O Concrete ❑ddigh Solids Bentonite
MATERIAL � from to ft. ❑ yds. ❑ bags
��C>�3 5C�]..� �i�'r:C fC `; �. ' � � irom to_ ft. ❑ yds. ❑ bags
~ from to ft. ❑ yds. ❑ bags
'� r ^ i �NEAR �0 lSOURCE OF Cpp�,MINATION
ti y<'i� bZ'Ob;F'i .� _, �_ `�.,, �. -rcf �
feet '---�G�✓/ )� direction'J� �� type
Well disinfected upon completion? ❑ Yes ❑ No
c�, y Gr��y �: . _ t �: i
PUMP
.�'ii4(: �z2 : VFT'1. l:(-�Z(:�' -�'tt �i i'-
� t �c- o❑ Not installed Date installed ��`��'
Manufacturer's name ��'f.! a��aC�CE.`�
i.t<1�� G7.��„'ti" �.; };: E j t��!. �odel number HP �� Volts ?'���
Length of drop pipe �� ft. Capacity 1�`� g.p.m.
;�t3,TlC�. � i.],T�r?j r9ZQy .��i �!.'!.! + � �J� tType: �T'6ubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
3 ABANDONED WELLS
:'�.�:il(� �C 1 t.�(�1 F.!`1I i �'i � :r i F ��S`' tDoes property have any not in use and not sealed well(s)? ❑ Yes �o
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes �TJo
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.
�2`-,Ft �.J�i�: :;�."tf'����rL`. L"v3Z"�.il� ��'1�.L1.ZlvV L.ls. � IjVC.
� �9�v Licensee Business ame Lic.or Reg.No. �� ~�
`�.iL� � -'� ",�� ; . _:-9�
. �.,�-
fi-�%�i%�'�� Authorized Representative Signature Date
..,} �
�%�° C�tti�i"1ri I�Sr7c,Y� '� (.;... i_`i'i
Name ol Driller Date
LOCAL ��r Y 5 9 6 d � � HE-01205-06(Rev.9/96)
,
v
Jcvin �itc� UVater ��inic, J�nc.
617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556
10/03/1997
Stodola Well Drilling
15306 Hwy 7
Minnetonka MN 55345
938-2111
REPORT OF WATER ANALYSIS
Lab#: 33651
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 10/01/1997 from the following location:
Peter Andrea
2995 Deer Run Trail
Orono,Mn
Unique Wiell#596661
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).
ter Clinic, Inc.
Bill
,4nalyical laboratory Coneultug Eiigmoer
Water A�ulysi�ReageNa Boilrn Watar C6omiwla
Lab Certdication Y 027-033-119