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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH
MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD � 6 7 3 H S H
Hennepin Minnesota Statutes Chapter�03!
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
�rono lI7 23 7 ,, ,, ,, 39b n I-9-02
House Number.Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
I170 Gacden C�� Orono 5535 �1 CableTool ❑ Driven ❑ Dug
1 I l Auger ,�Rotary ^ Jetted
Show exact location of well in section grid with"X". Sketch map of well location. I l ___ �
Showing property lines,
--�-—- --- -------
roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES ' NO
i N i , supe r ge I"g FROM ft.to_ ft.
__ ___ ___ _i_
USE L ❑ Monitoring ❑ Heating/Cooling
I I I I - -3 (`.<�y f� �� Domestic
_i_ _�_ _�_ _i_ - " � ❑ Irrigation � Community PWS �] Industry/Commercial
i i i i ❑ Noncommunity PWS ❑ Remedial
w e T _ �� t ❑ Environ.Bore Hole —
i i i � " ❑ Dewate�ing ❑
i � -r i '/zIM.1e x CASING/� Drive Shoe? Yes ❑ No HOLE DIAM.
_, _i_ _i_ _i_ � w f�'"� ,�fl�Steel ,k:] Threaded ❑ Weided
i i i i
❑ Plastic ❑
�1Mile� ,
CASING DIAMETER WEIGHT ,
PROPERTY OWNER'S NAME � in.to 38� I 1 Ibs./ft. ��n� Q
Charles Cudd Co. _--.—
Property owner's mailing address if different than well location address indicated above. in.to ft. __ Ibs./ft. �.�__ 6
275 Market S�� �7C4� 139 SCREEN OPEN��� 346
Minnespolis, MN 554�5 Make ��om h.�o n.
Type Diam.
SIoVGauze Length__
Set between ft.and ft. FfTTINGS:
STATIC T R LEVEL t
WELLOWNER'SNAME ___ n.�below ❑ abovelandsurface Datemeasured 1_�O�
PUM�ry��VEI(below land surface) � C 0
Well owner's mailing address if different than property owner's address indicated above. l ft. aker__._, hrs.pumping � g.p.m.
�LL HEAD COMPLETION �i�;��a��r
Pitless adapter manufaciurer �� Model
�❑ Casing Protection �12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? �}Yes ❑ No
HARDNESS OF Grout Material �❑ Neat cemQqt CI Bentp9itp ❑ Concrete .�J Fygh Solids Bentonite
GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO �
from_ « to '��� ft. f ❑ yds. ❑ ags
clap brown aoft p ig f�om ���o-3$�n. nature-I �y���� s
from to__._____ tt. ❑ yds. ❑ bags
NEAR T NO�WN SOURCE OF CONTAMINATION � /T(�
clsy/gravel gray soft I8 110 � feet �i'/__owz1� direction � ' r rype
Well disinfected upon completion? ❑ Yes ❑ No ��J C-�
gravel/clay gray soft 130 13T PUMP
clay gray �ediva� 137 �32 � Notinstalled Dateinstalled 1-�2-02
Manufacturer's name ���mfl t�r
Model number � HP __ ��� Volts �+3�1
clay/sand/gr vel grs soft 232 �77 —��
Lengih of drop pipe____ ft. Capaciry g.p.m.
sanda t one/�h Ie ye l i W� Type Ch Submersible ❑ LS Turbine ❑ Reciprocating ❑ Jet ❑
��� ��lu� 37? 39b ABANDONED WELLS �/.
Does property have any not in use and not sealed well(s)? ❑ Yes L�'No
VARIANCE
Was a variance gran[ed from the MDH for this well? ❑ Yes p No TN#
f
WELL CONTRACTOR CERTIFICATION
Use a second sheet,i/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.
Don Stodola ktell Drilling Co. inc 27 ?2
--- _ __ - ---
4N�- Lice e Busme Name or Reg.No.
�'`�' ��� _.�=.' , -'� 1-Z7-02
Authonzed Represe tive Signature Date
�,t,t�n� Math�ws ---- 1-9-02
Name ol Driller Date
LOCAL COPY 6 7 3 8 5 8 HE-01205-07(Rev.?J99)
IC#140-0020
� • �.
rw� c�-y w�� c � � � .r�,�.
617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556
Ol/11/2002
Stodola Well Drilling
3841 North Main
Sr. Bonifacius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab #: 28
Our Laboratory reports these analytical resulrs, determined on a sample taken
by CLIENT on O1/09/2002 from the following location:
Charles Cudd
1170 Garden Ct.
Orono,Mn
Unique Weii #673858
Coliform Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/1
The results of these cests indicate that this well is producing water that meets the
siandards for F.H.A., V.A., or conventional loans. This reporr is an analysis for
coliform and nitrate only and does not include analysis of Lead and other
contaminants. (Unless as specified by clien[).
. it Water Clinic, Inc.
Bil� ' s'dale
Lab Certification 1t 027-053-I 19