HomeMy WebLinkAboutwell info v. OC 1TION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
Ccunl .. am�_ ' WELL AND BORING RECORD Q ,
lJ ��f;2'1t1��J1P. Minnesota Statutes Chapter 103f � v � � � �
` Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed .��.�
C.;T�C,�n � �! i� U 1 1.�.� � e. j—.ii!--�%
v. �a v.
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
)�:t} ���f�};i::3 Lli1C�F�s. ri�i�t:.� V.L�L��IiJr S� ❑ CableTool ❑ Driven ❑ Dug
❑ Auger �Rotary ❑ Jetted
�� Show exact bcation of well in section grid with"X". � s Sketch map of well location. ❑
J�.f 6� Showing property lines, k,
roads and buildings. DRILLING FLUID
N t-�`s , .,_,.,,_ ,
- - ��, w�• . ,_.
� � � ,
; -,- -;- -,
USE y, ❑ Monitoring ❑ Heating/Cooling
i i i i X C] Domestic
_i_ _�_ _�_ _i_ ❑ Irrigation � Community PWS ❑ Industry/Commercial
i i i i ❑ Noncommunity PWS ❑ Remedial
w I I I I E� ❑ Test Well ❑ Dewatering p
i i i i +�2M.�a CASING Drive Shce? ❑ Yes ❑ No HOLE DIAM.
_� i i i_ � ❑ Steel ❑ Threaded ❑ Welded
� � � � C�Plastic ❑
s �
�1 Mile�
- CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME --t%�"ti '� �i in.to [:�� ft. ::�DI'ZG � Ibs.ttt. 7 �r{��y g G T
� c in.to ft. Ibs./ft. � rq � 7{
Hf3��"1� HC:�T���• _+ t�`� at. -
Property owners mailing address if different than well location address indicated above. in.to ft. Ibs./tt. in.to ft. -
SCREEN .7e7I�i ri c(;jl OPEN HOLE
Make r*.,,_._..; .,,'t �,..� Sr��� from ft.ro fl.
Type Diam. G
SIoVGauze 4" � Length E� �
Set between �'--� R.and L�^' ft. FITTINGS:
STATIC WATER LEVEL
WELL OWNER'S NAME �� / � ft.4�3 below ❑ above�and surface Date measured J j Z'—�
PUMPING LEVEL(below land surface)
':r:
Well owner's mailing address if different than property owner's address indicated above. �=t� ft. after � hrs.pumping - g.p.m.
WELL HEAD COMPLETION
�E�itless adapter manufacturer ��l t ��t+�i 1 Model
❑ Casing Protection �] 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? �i'Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement O�Bentonite ❑ Concrete l]{�igh Solids Bentonite
MATERIAL from � to �� R. ��J ❑ yds.�] bags
�� ``r ��� �'�, J `' .� from to ft. ❑ yds. ❑ bags
�•1 l� ¢ trom to ft. ❑ yds. ❑ bags
NEARE T K�fl SOURCE OF CO MINATIO�lf �7 1 7't-
.. p .��:/�I�
('1�y ��'� j �'`..� �S'% .-�.- teet direction �*_type
Well disinfected upon completion? ❑ices ❑ No
.�ar�c! ��n S �%�-' 1
< . s�rrt i���� ,>
PUMP
❑ Not installed Date installed �''-� �
�a��4 G�.�.�.t, � } ;�': a '/ ": IrAanutacturer's name -"�; �' �� _ ,.
.t
Model number 1"� '� r' ' �' Volts � -�
t �
1 1 - � kength of drop pipe ���J fl. Capacity � �' g.p.m.
(.1�";}.r �7 L L� :J ! /+�t C....+ �; •- �
Pressure Tank Capacity :� _ 1 i 7'i:�
Type: �Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
�
G'r;�v�l TC:�rt :a �'� �:�'. `
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? O Yes U�Vo
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes ❑;�o
WELL CONTRACTOR CERTIFICATION
Use a second sheet,it needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF DATA,etc. The intormation contained in this report is true to the best of my knowledge.
llC�P•. :.".[C:'L)tv:�j��� ���,a,�:� Ll�.i.LLIt:G C�:, , ?�iC.
Licensee Business l�lame ,-�Lic.orReg.No. `� '�'�i
,�
,-;�=''���/ / :��'� �, _.�, . ;_.S{;-^i t
Authorized Represenfative Signature Date
i����t. LF.�i.;_;r i-�v--y7
w� ,j � Name ol Driller Date
_ �£ ',.+i �i F �,
HE-01205-05(Rev.1/95)
� ' � Jwin �itc� UVater ��inic, J"nc.
617 13th Ave So • Hopkins, Minnesota 55343 • (612� 935 - 3556
OS/04/1997
Stodola Well Drilling
15306 Hwy 7
Minnetonka MN 55345
938-2111
REPORT OF WAT�R ANAI.XSIS
Lab#: 33159
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 07/29/1997 from the following location:
Hestia Homes
990 LOma Lfnda Ave
Orono�Mn
Unique 1Mell#68063a
Coliform Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/I
The results of these tests indicate that this well is producing v�ater that meets the standarcis for
F.H.A., V.A., or conventional loans. This repoR is an analysis for coliform and nitrate only and
does not inGude analysis of Lead and other contaminants. (Unless as specified by client).
�
� 'ty Wa�er Clinic, Inc.
\
Bill V ale
^°'iy'°'i ue°�°n' c�.,ru�a�
wuer audy.i�xetgam� so;ler wax c�e�o.V
Lb Cert'd�ic�tim f 027-033-119
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