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`b+/ELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
�' County Name WELL AND BORING RECORD � ���� �
Minnesota Statutes, Chapter 1037
� Township Na e Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
f�.
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r GPS DRILLING METHOD
LOCATION: Latitude _. degrees minutes seconds ,
Longitude . degrees minutes seconds =
Cable Tool ! �Driven j,Dug
� I Auger �otary ']Jetted
House Number,Street Name,City,and Zip Code of Well Location or Fire Number �
DRILLWG FLUID WELL HYDROFRACTURED? ���I Yes �- o
Show exact bcation of wel in section grid with"X". Sketch map of well location. ���r FROM ft.TO ft.
Showing property lines, -- -
� N �� � roads and buildings USE Monitorin
._ � _] g ,]Heating/Cooling
�:.. __; _ � � � �..,,,,� '� -i Domestic Environ.Bore Hole ,J Industry/Commercial
�' � �� ,Noncommuni PWS �] g '�Remedial
ty [ Irri ation
• J Community PWS ❑Dewatering ' i_
� � � CASING . HOLE DIAM.
�� w , , e T Drive Shoe? �Yes �o `
�. ._,_____;_ _� �__ I 0�r ', ❑Steel I �Threaded �,�W ded `
'hn�tiie �F� lastic � __
, ' -' � � 1 CASWG DIAMETER J WEIGHT
S
� in,to �� ft. ��0� IbsJfL � in.to� ft
�—i M�ie—� ��j�
in.to ft. Ibs./ft. �in.td"' ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. IbsJft. in.to ft.
�� SCREEN_ OPEN HOLE '
� Property owner mailing a ress if different than well location address indicated above. Make �8� . FROM �ft. TO ft.
' (� y1 �* Type 9� '�t1� !R-q�� Diam
'� ��"— ��i�'� � i� Slot/Gauze_ ___ ._���_ Length��__��
{,, t� Set between ft.and R. FITTINGS M
P��Cl4i � SS��iV STATIC WATER LEVEL
�^" ft. elow i_above land surface Date measured__�a� "-'
PUMPING LEVEL(bel land surface)
-% WELL OWNER'S NAME/COMPANY NAME I�S ft.after � �
, hrs.pumping g.p.m.
W�LL HEAD COMPLETION � � '
Well owner's mailing address if different than property owners address indicated above. �pitless adapter manutacturer `�-_ �
❑Casing Protection '�'(2 in.above grade
�At-grade(Environmental Wells and Boring ONLY) T
GROUTING INFORMATION,,.��-,,,///
_ Well grouted �es U No ,�,�(�
Grout material Neat cement ❑Bentonite i]Concrete I�'IHi h Solids Bentonite
from O to � ft. r � � ds. ags
trom�to� ft. �� �����ags
� GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from___ to ft. �,-_yds. ❑bags
MATERIAL
NEAREST KNOWN SOURCE OF CONTAMINATION
_ �l�,�__feet ...�.: direction ��type
Well disinfected upon completion Yes ,.�No
PUMP
j,,,�.
� j _Not installed Date installed ,,..i � �„�� �.�� _
Manufacturer's name ��
i/ -
Model number HP�/�Volts � � �
Length of drop pipe f��Ef ft. Capacity g.p.m.
Type:. bmersible ❑LS.Turbine '�Ji Reciprocating �Jet ❑
ABAN ONED WELLS
Does property have any not in use and not sealed well(s) [;Yes o
VARIANCE
Was a variance granied from 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,etc. u�Ai �todola Weli Drillicag Co,. IEIC• L7��L
Licensee Business me �7 '.or Reg.No.
i
'-7. � -.�_ ��!
'e epresentative Si naty2 Date
�.. ViiVi.:� �7W��
LOCAL COPY `� ('� �(�3 � NameofDriller
' � '"'f � HE-01205-08(Rev.5/02)
� IC 140-0020
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617 13th Ave So � Hopkins, Minnesota 55343 � (612) 935 - 3556
OS/20/2004
Stodola Well Drilling
3841 North Main
St. Boni facius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab #: 382
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 05/I S/2004 from the following location:
380 Leaf St.
Orono,Mn
Unique Well #705939
Coli form Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/1
The results of these tests indicate that this well is producing water that meets rhe
standards for F.H.A., V.A., or conventional loans. This report is an analysis for
coli form and nitrate only and does not ►nclude analysis or�ead and orner
conraminants. (Unless as speci fied by client).
" City Water Clinic, Inc.
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BI�� L�L��B
Lab Certifica[ion#027-053-119