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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UN/QUEWELL NO.
�: County Name WELL AND BORING RECORD
� Minnesota Statuf�s;"Ch"�'�f 1037 ��' 5�f��
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed � �
�, �, ,, �� 145 f� �2��
GPS DRILLING METHOD
-. LOCATION: Latitude degrees minutes seconds �
f`���Cable Tool '���Driven ��Dug
¢� Longitude _ degrees minutes seconds - 'Auger �Rotary ' �;Jetted
House Number.Street Name,City,and Zip Code of Well Location or Fire Number
DRILLING FLUID WELL HYDROFRACTURED? �, ,Yes � � o
Show exact location of well in section grid with"X. Sketch map of we!I I cation. �rej' FROM ft TO ft.
Showing prope y li s,
;� N L roa��d il� USE �Domestic O�En iron!Bore Hole �'Heating/Cooling 6
♦ ,
� J J ' � ���J � �Noncommuni PWS L.]Industry/Commercial ;
�� , ; � (� . ty ❑Irrigation �]Remedial
; , ; , , *-+� �1 z L Community PWS [�Dewatering �" -
�-^ CASING HOLE DIAM. k
w e 1� Drive Shoe? '�'��.Yes �No
� ' ' ' �^�-�------� �Steel ��`Threaded �Welded
, . _� T ;� _.. �
� : ; : - .-- ,_ -
� 'h Mile � Plastic _
LJ
�,� ' ' � � 1 CASING DIAMETER WEIGHT
� I S ; � • q� �� *"�
� .�tL� � � in.to i�" ft ���� Ibs./fl. in.to �ft.
�-1 Mile—� t� (�� �— j
�� in.to it. IbsJk. �+�__in.t�"'f� ft.
PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft. in.to fl.
SCREEN OPEN HOLE -
Property owner's mailing address if different than well location address indicated above. Make FROM ft. TO ft.
� 1844 Wayztta ���s � �1J TYpe—� —_ Diam.
� i w� � C��� SIoUGauze ���� Length�_.._ ._ _
Lxi � a Set between_, ft.and ft. FITTINGS
STATIC WATER LEVEL
� ft.�_ elow ❑above land surface Date measured �J—llJ
�� r PUMPWG LEVEL(below land surface)
� WELL OWNER'S NAME/COMPANY NAME �� q . �/�
ft.after 4 hrs.pumping____ '►V g.p.m.
WELL HEAD COMPLETION .yj
Well owner's mailing address if different than property owners address indicated above. �'7�pitless adapter manufacturer �iu��t� ._ Model _
�f�
_!Casing Protection �2 in.above grade
'��]At-grade(Environmental Wells and Boring ONLY)
GROUTING INFORMATION,,,���,,,,,,ff(���
Well grouted �es , ',No
Grout material J Neat cement []Bentgon�itye �_J Concrete�High Solids Bentonite
from � to -�N ft. .7 �,yds. 'I'3etlags '�
from � to�J4 ft,�tu�ai ����. �lbags `�
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO from to ft �_�,yds. �,�ba s
MATERIAL 9
NEAREST KNOWN SOURCE OF CONTAMINATION
L'I8�► yello� a�c►ft 28 _ � feet .�f.! direction 'type
Weli disinfected upon completion �es �No '�',�,y._t:_.`�.>_,>}
— ...._,..,_ . _.
C18y gCSy BOft ZS iZO PUMP :
-�.Not installed Date installed_ Zt+�`1L."VJ �
Manufacturer's name a
: asnd tan soft 3.ZQ t45 Ae�at�€ _
Model number ___ HP__���oRs�___
Length of drop pipe Z0� ft. Capacity g.p.m.
�'`��� Type:�� - Submersible ❑LS.Turbine ❑Reciprocating ❑Jet
��
� ABA ONED WELLS
Does properry have any not in use and not sealed well(s) [.,!Yes j_. o
VARIANCE
Was a variance granted 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 ����'1 .
•• REMARKS,ELEVATION,SOURCE OF DATA,etc. l/IRiJC�OlII �elLnrilifc,� ��S ILIC• �7i7L
Licensee Business Name Lic.or Reg.No.
a'
ut r� pres tativeSignat�re �'��� Date �
Chuck i+�oore 12-5-03 �
7 ��� �Q Name of Driller �
LOCAL COPY i
- � H607205-OB(Rev.5/02)
IC 140-0020
.�
. . _ �
rw�. c�y w�-� c � � � r�,�
617 13th Ave So � Hopkins, Minnesota 55343 • (612) 935 - 3��56
12/10/2003
Stodola Well Drilling
3841 Norrh Main
St. Bonifacius MN S�375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab#: 1116
Our Laboratory re�,�rts these analytical resulis, determined on a sample taken
by CLIENT on 12/0�`�/2003 from the following location:
28T0 Little Orchard Way
Orono,Mn
Unique Well#705900
Coli form Bacreria <1/100 ml
Nitrates Nirrogen <1.0 mg/1
The resuJts of these te��rs indicate that this well is producing water that meets the
standards for F.H.A., !!A., or conventional loans. This report is an analysis for
coliform and nitrate unly and does not include analysis of Lead and other
coniaminants. (Unless as specifed by client).
rt�rn City Water Clinic, Inc. �
.�\��\
Bill.��c�i�lbtr3dale
1
Lab Catification#027-053-I 19