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WELL�OCATfON MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUEWELL NO.
County Name WELL AND BORING RECORD � ,� ...
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� i,�,! Minnesota Statutes, Chapter 1037 �, �? !.; � ,1
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed �
dra�v 118 23 32 �� �� �� 18€3 ry 11-2I�
GPS DRILLING METHOD
LOCATION: Latitude degrees minutes seconds
Longitude degrees minutes seconds I.�Cable Tool �Driven � ���Dug
J Auger �Rotary �Jetted
House Number,Street Name,City,and Zip Code of Well Location or Fire Number � �-�
.7V'!V d�{,.�i !'lili Ad OrOIIO 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o
Show exact location of well in section grid with"X". Sketch map of w II location. ��e'�
�howir�y pro erty Iines, FROM_ }t.TO ft.
N �ads a buildings USE —
t,►1 ��vff Lj Monitoring ��Heating/Cooling
� � � � �Domestic �Environ.Bore Hole �._,Industry/Commercial
-'-- --'-----`----`--
v Noncommunity PWS ❑Irrigation . �,Remedial
� L Community PWS ]Dewatering �_
--'----i--- --`-- --`-- -
W i ; ; i E� ASING Drive Shoe? ❑Yes �No OLE DIAM.
�� � ' ' ��'le GA[/.;' j� • t� R. � �Steel ����Threaded �Welded
--�--- --�--- --�-- ' I H
'/Mile 18StiC �
__;_____,;_""'�_____;__
1 �� CASING DIAMETER WEIGHT
, , S , , �'`il q 1
�1 Mile—� � �in.to__._�ft. G��l Ibs./ft. �in.to�ft.
! �p�
._in.to ft _ Ibs./ft. �in.tojQ�Qft.
PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to ft.
Bob Fitc�h Constnuticm SCREEN OPEN HOLE
Property owner's mailing address if different than well location address indicated above. Make ���� }� FROM ft. TO ft.
11725 54Lh AVe N Type��-u�'�"�/�'�+ Diam.
_ ._ —. .._�—A ___
P� tL � ttLLq SIoUGauze_ __.,,,_ •41V Len th '�'
� �I� JJ�4ff4 9 N �
Set between___���_ft.and��fl. FITTINGS
STATIC WATER LEVEL *
95 ft below �.J above land surface Date measured �a_���
PUMPING LEVEL(be ow land surface)
WELL OWNER'S NAME/COMPANY NAME
1� ft.after 'L hrs.pumping 2S g.p.m.
W L HEAD COMPLETION -�-d t�t�r
Well owner's mailing address if different than property owners address indicated above. Pitless adapter manufacturer__�111 Model
;Casing Protection �12 in.above grade
���j Abgrade(Environmental Wells and Boring ONLY) -
GROUTING INFORMATION �
Well grouted �Yes ❑No
Grout material . _Neat cement C-Bentonite I��Concrete High Solids Bentonite
from_�_.to�,__ft _ �yds. �bags
from__�to�,,�_fl. ����j�, [ �bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft. �yds I._�bags
MATERIAL
NEAREST KNOWN SOURCE OF CONTAMINATION �
Cl$ ��� �i� 0 16 �....� feet � l./_/ direction Ji._,__,.'-'-1�•_• tyPe
Well disinfected upon completion Yes []No
C18 CS SO.gL �E� �2O PUMP
❑Not installed Date installed__ �� �
�Y.! $ $��� �ry� ��� Manufacturer's name
ii�i[A1 bl/ q
Model number _ ____HP�Volts L.�
C � �f� i"jG '175 Length of drop pipe 146 ft. Capacity g.p.m.
Type: Submersible � '��LS.Turbine L,Reciprocating �Jet ��
� b�� �ft 1'l� 1W ABANDONED WELLS
Does properry have any not in use and not sealed well(s) �Yes o
VARIANCE
Was a variance granted from the MDH for this well? I �,Yes . No TNk
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 � �=�O'+ �� ��� ^�i' *�• ����
REMARKS,ELEVATION,SOURCE OF DATA,etc. iX� v{,T y
Licensee Business Name Lic.or Reg.No.
� r""
� ,.-� '�, _ - 2�17-11.7
Aut oriz epresentative Signatur�� Date
� i RJil�
LOCAL COPY NameolDriller
71 � � � 3
HE-01205-OS(Rev.5/02)
IC 140-0020
1 -
rw�. c�-y w�-� c � � , r�
617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556
1 1/15/2004
St-odola Well Drilling
3841 Nort-h Main
St. Bonifacius MN 55375
938-21 1 1
REPORT OF WATER ANALY5IS
Lab #: 893
Our Laborarory reports these analytical results, derermined on a sample taken
by CLIENT on 1 1/1 1/2004 from the following location:
3640 Jacobs Mill Rd
Orono,Mn
Unique Well#719803
Coliform Bacteria <.1/100 ml
Nitrares Nitrogen <1.0 mg/1
The results of these tesrs indicate thar this well is producing water that meets the
standards for F.H.A., V.A., or conventional loans. This report is an analysis for r
coliform and nitrate anly and does not include analysis of Lead and other .
conraminanis. (Unless as speci fred by client).
.
win City Water Clinic, Inc. � � "
eil rsdale
� Lab CeRification#027-053-119