HomeMy WebLinkAboutwell info„ WELL LiCPTION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
��,ntyName WELL AND BORING RECORD �- /y �
���� Minnesota Statutes Chapter f03! °'j 9 �� � �
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
fl.
'�.rartc� 11 e �3 U7 ��. ��. ��. 2C�8' �-��i-y6
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Du
4h 15 FflL'Z�t Lake Ix^•Ilc1 S C)Z'ollc� .`�a64 g
/ / ❑ 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
N �Zt�1 t�G�
� � � � l,u/�L�.
-; -;- -;- -;
USE ❑ Monitoring ❑ Heating/Cooling
' i i i i �7 Domestic ❑ Communit PWS
-'- -�- -�- -'- ❑ Irrigation y ❑ Industry/Commercial
i i i i � Noncommunity PWS ❑ Remedial
w E T ❑ Test well
i i i i ❑ Dewatering ❑
i i i -r �/zlM�a CASING Drive Shoe? ❑ Yes �No HO�E DIAM.
_i i i i_ I ❑ Steel ❑ Threaded ❑ Welded
; - ,- -, - -, 1
� Plastic ❑
S
�-1 Mile-�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME Ei n in.to �C>t: ft. �.g Ibs./ft. f J�%
�.�_n.
Kei i:.n Vk�ter�� & ls:�;�x�:�,t���� • ��.to n. ibs.in. {�/�
Property owner's mailing address if different than well location address indicated above.
in.to ft. Ibs./ft. _�-i�{t����
�I[�.���,.(j Vl�CS� D�7�Ve SCREEN OPEN HOLE
S�.e. 7� i��� Make ����n from ft.to ft.
Fcien Pr.�3irie, �l. �J�'1'�J�� Type 5�2III�iS rJt2�1 Diam. `
SIoUGauze �(��/�� Lengih � �
Set between tt.and ^.r�o ft. FITTINGS: �' � � �
—��
STATIC WATER IEVEL
�
WELL OWNER'S NAME `=t% ft. C�below ❑ above land surface Date measured �- �-y6
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. ft. after hrs.pumping�� � 11L� 9 P m
WELL HEAD COMPLETION
�Pitless adapter manufacturer �'tl'�'Q�,$ PT Model
❑ Casing Protection_ C�12 in.above grade
❑ At-grade(Environmental Wells and Borings ON�Y)
GROUTING INFORMATION
Well grouted?�7 Yes ❑ No
HARDNESS OF Grout Material ❑ Neat cement ❑ eentonite ❑ Concrete F}i h Solids eenronite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �C.,;9 G
from �� to �t�ft. G•-� ❑ ydsXE7 bags
from to ft. ❑ yds. ❑ bags
(��� � � (t A ,��j; from to ft. ❑ yds. ❑ bags
NEARE-ST-�KN,yOW-N SOURCE OF CONTA�A/T1ION ���•�
�.�.d ..57_Z� �E' .rC :3 ��'E±t ��3; �L�a � feet L., /"a s%� direction � � type
Well disinfected upon completion? ❑ Yes ❑ No �
Cla � & G.r������1 B-r��,� i� 1�,�' i 95 t PUMP n
❑ Not installed Date installed ��-'"��"7�!
W"c1�E.'Y Sc�IICi (�(:3�'JI"t,:X.l' S �3�;i L�s8t Manutacturer'sname1��T�����CS� j�_��,3
Model number HP � Volts
Length of drop pipe �� ft. Capacity �� g.p.m.
PressuXreTankCapacity �2r� �-^IY'��
Type: L7 Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes �4 No
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes [�No
WELL CONTRACTOR CERTIFICATION
Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE��,��� The information contained in this report is true to the best of my knowledge.
DC7N S`tODC)Lta iro�,,L DRI.I,LING CO., IItiIC. `L7172
F E g 2 p 1997 Licensee Busines�s Name , Lic.or Reg.No. '
_ �' 1 8-26-y6 $
C4!�C�F C�RCNO �Auth rized Hepr entative Signature Date
cnuck r�_�e t�-;�6-Sf�
� ��`,,, �� Name ol Driller Date
LOCAL COPY "��
��� HE-01205-OS(Rev.1/95)
�,' Jwir� C,itc� l/Vater C,�inic, J�nc.
, 617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556
09/04/1996
Stodola Well Drilling
15306 Hwy 7
Minnetonka MN 55345
938-2111
REPORT OF WATER ANALY"SIS
Lab#: 30757
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 08/28/1996 from the following location:
Keith Waters
4415 Forest Lake Land.
Orono,Mn
Unique W�ell#573587
Coliform Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/I
The results of these tests indicate that this w�ell is producing water that meets the standards for
F.H.A., V.A., or conventional loans. This report is an analysis for coliform and nit�ate only and
oes not include analysis of Lead and other contaminants. (Unless as specified by client).
\ '�
� �
Twi �ty� ter Glinic, Inc.
,\
Bill Va A d I �\
�.,
�
Analyical laiwratnry Correultirg F:ngincer
Wa[er Analysis ReageNa Boiler Water Chemicale
l,ab Certilication!1 027-033-1 l9