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WELL LOCATION� MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUEWELL NO.
County Name WELL AND BORING RECORD
Minnesota Statutes, Chapter f037 ��' ��� �
Township a e Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Comple[ed (�
fl.
i� i� ,�
C' DRILLI G THOD
LOCATION: LatiWde degrees minutes seconds
�Cable Tool I, i Driven �-�Dug
Longitude degrees minutes seconds � � - �
�� �Auger otary � �Jetted
House Number,Street Name,City,and Zip Code of Well Location or Fire Number U `J
DRILLING FLUID WELL HYDROFRACTURED? ;]Yes o
Show exact location of well in section grid ith"X". ���----�h map of we!I location. �$�ej,' FROM ft.TO � ft. �'
howing property lines,
N roads and buildings USE �
❑Monitoring ❑Heating/Cooling �
i� omestic �Environ.Bore Hole ❑Industry/Commercial r
� � �(y � '�Noncommunity PWS f��]Irrigation ❑Remedial ;
I I I I _, _
I I I I / }�' ❑Community PWS ❑Dewatering ❑
--'----'-----`-- ---`--
W i i i i E� A IN Drive Shoe? ��,Yes �o OLE DIAM. ..
S G
— H
--;--- --;--- -_�_ ___;_ � I Steel [Threaded ❑W Ided
� 'h nniie lastic '
' � r � 1 CASING DIAMETER WEIGHT �
S
��Miie—� _._—�-_in.to �f1LA ft. �!.n� Ibs./ft. �in.to�ft.
�RL�
, _. in.to __,____ ft __, IbsJR. LI.. in,to�3/.Oft.
PROPERTY OWNER'S NAME/COMPANY NAME �� 7�if .
in.to.__ ft. Ibs./ft. in.to ft. '
�er Building Corp SCREEN OPEN HOLE
Proper.y owner's mailing address if different than well location address indicated above. Make �� �� FROM ft. TO ft.
3435 Cty �r.l lUl Type----��� �- Diam.
�.2��t�RRiRA� A�+I 55345 SIoUGauze� 8 h/��8S a�l Length��� /
Set between •�1V ft.and__. ft. FITTINGS+i� '�''i t
STATIC WAT EL � �
11� ft elow �;above land surface Date measured TJRl�4
PUMPING LEVEL(below land surface) ��
WELL OWNER'S NAME/COMPANY NAME ��� � � /� .
...._4,1_�ft.after Z hrs.pumping 4SJ g.p.m.
WELL HEAD COMPLETION • .9� t—� .
Well owner's mailing address if different than property owners address indicated above. .Pitless adapter manufacturer v-�J��� ��..-J.SLr�a.}'��i.�"filAdel � ���
�Casing Protection �12 in.above grade
❑At-grade(Environmental Wells and Boring ONLY)
GROUTING INFORMATION �
� Well grouted es U No .
Grout material J Neat cement ��Bento�ni/te�;J Concrete igh Solids Benronite ��
from g�Q to ./7�t1 ft. 3 �yds.t�ags �
from .71J to ZyIJ__ft. ����1 j��1�ir'bags
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft []yds. jJ bags
MATERIAL
NEAREST KNOWN SOURCE OF CONTAMINATION
(�`la5/ yE.aI��T $�ft � 26 �� feet _direction '''���- type
�
Well disinfected upon completion es ❑No �
Clay �T.$�T S'�O1C Z� 1W PUMP f,.
� �Not installed Date installed �`C? � ` �� ;'
$�'j(� c+�att f�f C 1� 'i� Manufacturer's name .,f�"r��_a3---i�-r"S"'.� ���
d J r^�,
Model number HP_.-.,�� Volts �� � �..J �.
C�yJ r�lC� gr8'y �.f(� y.�/ �,yp Length of drop pipe � ��� � ft. Capacity g.p.m.
Type:�. � ubmersible ❑LS.Turbine [__]Reciprocating �;Jet [j
sarxi/gravel br�[� ��� � 6�8 ABA ONED WELLS
Does property have any not in use and not sealed well(s) I I Yes � o .�
VARIANCE
Was a variance granted from the MDH for this well? ��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 a
REMARKS,ELEVATION,SOURCE OF DATA,etc. a�V[; Stodola �lI Drilling Co�r� �• G717L �.
Licensee Business Name Lic.or Reg.No. :
o r se t ive igna(we Date
C�l.�t I�'IOdC� 5'��i
Name ol Driller
LOCAL COPY 7 � '� �� Q, -
HE-01205-08(Rev.5/02) _�
IC 140-0020
C • �
rw�,�, c�-y w�-� c � � � , r�,�
617 13th Ave So � Hopkins, Minnesota 55343 • (612) 935 - 3556
05/05/2004
Stodola Well Drilling
3841 North Main
St. Bonifacius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab #: 318
Our Laboratory reports rhese analyrical results, determined on a sample taken
by CLIENT on 05/03/2004 from the following location:
560 Kokesh Farm Rd.
Orono,Mn
Unique Well#705914
Coli form Bacteria <1/100 ml
Nitrares Nitrogen <1.0 mg/1
The results of these tests indicate ihat this well is producing waier rhar meers 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 other
contaminanrs. (Unless as specified by client).
i City Water Clinic, Inc.
BiN\ Arsdale �
��
Lab Ce�tification#027-053-119