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WEL�LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
�a���Y .;,� WELL AND BORING RECORD � y�
Minnesota Statutes Chapter103! � � � U � �
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
n.
v. v, i.
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
i i Cable Tool ❑ Driven ❑ Dug
J Auger �Rotary ❑ Jetted
Show exact location ot well in section grid with"X". Sketch map of well bcation. C _.___ .
Showing property lines, -- ��- -
_- _ � roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �10
N f•
i i i i �(j,.i� �IIB��C .FROM ft.to___ _—fl.
i l i -i •
USE ❑ Monitoring ❑ Heating/Cooling
i i � i �Domestic
_i_ _�_ _i_ _i_ ❑ Community PWS [�7 Indusiry/Commercial
i i i � �.�,,,,V.,,..____---- ._ Irrigation ❑ Noncommunit PWS
w E - 'X ❑ Erniron.Bore Hole Y ❑ Remedial
� � � i T „��...�• ❑ Dewatering ❑
i i i i +zIM1e �'..' CASWG Drive Shoe? �Yes ❑ No HOLE DIAM.
_i _ i_ _i_ _,_-, � � fi�Steel �Threaded ❑ Welded
i- i i i
�7 Plastic ❑
�-1 Mile-� ��
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME �__m.to��_k. _�_�__ Ibs./ft. �__in.�o___�l�
in.to__ ft. _._- -- Ibs./tt. ��in.�o_�
Property owner's mailing address if different than well location address indicated above. ____. in.to R. __ Ibs./ft. '4 ' ,to
27� Market �1� Ote 1J9 SCREEN OPENHOLE
�,�r C n Make from fLro_ ft.
Minneapolis, i'31Y )S�V� Type_ ___ _Diam.
SIoUGauze Length_
Set between ft.and ft. FITTINGS:
STATIC WATER LEVEL
WELL OWNER'S NAME __���_______ft.�below ❑ above land surface Date measured � 1_'t 9� �f
�1—iJ 4 .
PUMPING LEVEL(below land surface)
Well owner's mailing address if different than property owner's address indicated above. ______�3.�____ft. after._ __�_ hrs.pumping L�g.p.m.
WELL HEAD COMPLETION Qhi t ewa t e r
❑ Pitless adapter manufacturer _ __ _ Model
❑ Casing Protection _ __ ____ ❑ 12 in.above grade
. Cl At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? ��`/Yes ❑ No
HARDNESS OF Grout Material Cl Neat cement ❑ Bentonite CJ Concrete �High Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO
from___�._.to_��R _ __�_ ❑ yds.�bags
Y � from__ to tt. � Y�.� ba9s
cla e1ZoW sofr � from ��o ��-h. n��� � ba 5
NEAREST KNOWN SOURCE OF CONTAMINATION �
clay �r$y $�f�,` 2 t� __--feet _ _ direction ____ ._type
Well disinfected upon completion7 es ❑ No
sa�� �j�ay 5��� 9 13 PUMP
[I Not installed Date installed 11'G V`V 2
�l�y �jra� medium �J 23 Manufacturer'sname _��_@_�
�� �y+� Modelnumber_________. _. __ _ ___ HP _..__�_ Volts __�_�___ ��,.
fine .g��� gray ��d�U� 4.7 Z� Lengthofdroppipe t r,R _ ft. Capacity _ ____ ___gpm.
/ Type: ❑ Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
elay/rocks r8 mediu�e 2`� �� ABANDONEDWELLS
i p p Does property have any not in use and not sealed well(s)? C Yes o
g�.nd.�tOn� ra il8�d �v �v VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes f o 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,et0. The intorm�tion contained in this report is true to the best of my knowledge.
Drone casing 38Q-382 -�oir�����s�,�N�}��rf3�-f��w��.� 172
A�, ¢ RepreS ta roe Si tur ` � � 'D����-
_ . _�112��1'�DC3t-�#,. 1 1—iT�_(1� f
��- � Name ot Driller Dale
LOCAL COPY � 7 ��9 5 HE-01205-07(Rev.7J99)
\ IC#140-0020
_. r�� c�-y w�� c � � , r�,�.
617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556
11/15/2002
Stodola Well Drilling
3841 North Main
�t. Bonifacius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab #: 1175
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 1 1/13/2001 from the following location:
1140 Garden Ct.
Orono,Mn
Unique Well #677895
Coliform Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/1
The results of t{�ese 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 oiher
contaminants. (Unless as speci fied by client).
�'i�vi \E'ty Water Clinic, Inc.
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Lab Cert�cation H 027-053-119