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` M/NNESOTA UNIQUE WELL
WE�L OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO.
� CountyNa e WELL AND BORING RECORD ����� �
� Minnesota Statutes,Chapter 1037
� Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED
�`� c� l! 3 4� � �,,,�t1�- � " '� h � -�:.�/ r c�
. GPS DRILLING METHOD
LOCATION: Latitude degrees minutes seconds _
� I Cable Tool �-'Driven �' ��Dug
Longitude degrees minutes seconds i �� �
, _ Auger �otary,.,_ C Jetted
� House Number,Street Name,City,and Zip Code of Well Location or Fire Number ---� .
+�� �� ,# � � � _ ���-?c°' RILLING FLUID p!L HYDROFRACTURED? [�.Yes o
r���
Show exact location of well/boring in section grid with . Sketch map of well/boring locatio . � �^�� � From ft.To ft.
Showing property lin ,
N roads,buildings,and directi USE �,�-�,y/mestic �]Monitoring ❑Heating/Cooling
� � � , � �_f.., .
__�____.:____L_ ___:_ [�Noncommunity PWS ❑Environ.Bore Hole �L]Industry/Commercial ���
=Community PWS ❑Irrigation ❑Remedial �
--'---�--- ---`-- --'-- ❑Elevator ❑Dewatering ❑ ' �-
'�'� E T CASING MATERIAL — '_,
Drive Shoe7 _j Yes ;�l�o HOLE DIAM.
I �� �` __Steel ❑Threaded ❑Welded ��
, , , , '/x Mile -
� � � � � , astic f]
--�-----r-- ---�-- ---�- � � �
� ASING
� � g � � s� - iamet�r Weight � Specifications {
F �j']/� �
�i M�ie� �in.to_����tJ'�r✓ft. �Ibs./ft. � s��in.to
PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. J �/ to
`1 ��. �.
� qs�_u � � � in.to ft. Ibs./ft. in.to ft.
� '' OPEN HOLE
Propert owner's mailing addre�ss-i^f different than well bca``t^^io��n address indicated above. SCREEN �R('jYl d1„`�y!!'Y"`�
�t � � � ����11a y„��] Make From fL To ft.
fi z � �
Type y�Z� c1� � �v..i � � Diam. t' {'
f}�`��, �` 3 SbVGauze r ..�J �l�' �+` Length 7 � 7
� ,�""J" "��� �"���� �� �~ "'" � � Set between ft.and_-�y�ft. FITTINGS r ���
i
STATIC WATER LEVEL
Measured from
� � �� ft� �low j.1 Above land surface Date measured �`�� �-�
WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface)
� � � ft.after � rJ hrs.pumping w i� g.p.m. -
�i . Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION '
i S� �
�� r�itless/adapter manufacturer �}1�f-�-",-'-"'`''���odel
�. ��Casing Protection �2 in.above grade �
❑At-grade(Environmental Well and Boring ONLY)
GROUTING INFORMATION
Well grouted es ,__J No
- Grout materials i_ Neat cemeM [�entonite ❑Concrete ';�Other _
From�To .��ft. __ '��/ ❑Ydjs�. g[,�ags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From �� "� To :.�1'.�.Jft. �C� IfAr�1�YUS: �K''Bags
�" MATERIAL �
. From��To��. �( � ds. ags
NEAREST KNOWN SOURCE OF CONTAMINATION �)
,.� � �..
} .. ;�- a � �.
� `� �'J f�� feet _ �"" direction :.:'� type
�+'') t Well disin(ected upon completion? es �'No
1,,,,,,�[ N' ��r�t � �'"7 ��� UM P
{ /y` , ❑Not installed Date installed r� �� � ��
�'� f��� �' � �� � ` +y� Manufacturer's name � . `<<">'�` -��r�✓
�� � (,_. , �j - - -� Model Number HP�Volts 1���
,i��. �'..�}3���V. `� ��'. ��I 5:��". Length of drop pipe /4L)�. j
� �./ tt. Capacity g.p.m.
Type:��. ubmersible ❑LS.Turbine ❑Reciprocating ❑Jet ❑
�� ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑Yes [ o
VARIANCE
Was a variance granted Gom the MDH for this well? J Yes � o TN#
WELL CONTRACTOR CERTIFICATION
� This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
The information contained in this report is true to the best of my knowledge.
Use a second sheet,if needed.
REMARKS,ELEVATION,SOURCE OF DATA,eta - �
�n ,� �c�� �� a(�l� ff J,,,,; �'rk..
Licensee Business Name Lic.or R .No. ♦/ � `
�{,Ci r
__ _ _� �� ��
� e ese a i Sig a r - Certified Rep.No. Date
LOCAL COPY 7 �' � 1 �'-'"�U C' I� ��j' �-�C./��L '�
. � 0� -'--+� Name of Driller ��. � . . #�
IC 140-0020 HE-01205-11(Rev.3/07)
� �
7�w i�w C i�"y 1�tI a.t"e�v' C ' ' , I v�,c�.
617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556
OS/25/2008
Stodola Well Drilling
3841 North Main
St. Boni facius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab #: 388BN
Our Labovatory reports these analytical results, determined on a sample taken
by CLIENT on OS/21/2008 from the following location:
3300 Graham Hill Rd
Orono,Mn
W elL 760611
Colifovm Bacteria Absent
Nitrates Nitrogen <1.0 mg/I
Arsenic <2.0 ppb
i�/
Twin C� Watev Clinic, Inc.
�
Bill��� vsdale
Analyical laboratory Consulting Engineer
Water Analysis ReagenLs Boi]er Water Chemicals
Lab Certification#027-053-I 19