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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
CountyName WELL AND BORING RECORD � 7 � �O o
���n Minnesota Statutes Chapter 103I
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed "
Orono lI7 23 3 ,,. ,,. ,,. ., 207 " 7-22-�96
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
�Gtl �TI�.y�� vLl� �QI� 5535b ❑ Cable Tool ❑ Driven ❑ Dug
❑ Auger � Rotary ❑ Jetted
Show exact location of well in section grid with�".1��+ " Sketch map of well location. ❑
�� Showing property lines,
1 (}� roads and buildings. DRILLING FLUID
N �
_� � � �_ X��Cl. Water
_ ___ ___ _'
USE ❑ Moniroring ❑ Heating/Cooling
� � i � t�J Domestic ❑ Communit PWS
_i_ _�_ _�_ _i_ ❑ Irrigation Y ❑ Industry/Commercial
i i i i ❑ Noncommunity PWS ❑ Remedial
w I i ' E �� ❑ Test Well ❑ Dewaterin9 ❑
i i i i � CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM.
VZn+ae
_i i _�_ _i_ � ❑ Steel ❑ Threaded ❑ Welded
� -�_ � � � Plastic ❑
s
�-1 Mile�
CASING DIAMETER WEIGHT 1 '�(�
PROPERTY OWNER'S NAME 4 in.to 198 ft. '����' Ibs./ft. �� `����j'�'`7(
���1 �t�s bt su78� in.to ft. IbsJft. v$ in.to ""'ft.
Property owner's mailing address if different than well location address indicated above. in.to R. Ibs./ft. in.to ft.
1�.7`tO V 1 R[�'7 i�i� SCe 11Q SCREEN�_ OPEN HOLE
Fxien Prairie, *8�1 553�►4 Make � St�� from ft.to ft.
Type Diam.
SIoVGauze Length
Set between �7 ft.and_lg�ft. FITTINGS:11��M
STATF6tY✓ATER LEVEL �! q�
WELL OWNER'S NAME �� ft. � below ❑ above land surface Date measured �si
PUMPIN('x►EVEL(below land surface) � /n
Well owner's mailing address if different than property owner's address indicated above. Z�7 ft. after hrs.pumping �1J g.p.m.
WELL HEAD COMPLETION T_A„1�tLI
� Pitless adapter manufacturer ��i11 Model
❑ Casing Protection C?12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFORMATION
Well grouted? L'S Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement C9 Bentonite ❑ Concrete ❑ High Solids Bentonite
MATERIAL _�__to�g. _'�_ ❑ yds. ❑ bags
from
Citi� `�g�'�� �ft Q '� from to ft. ❑ yds. ❑ bags
j,r..
from to ft. ❑ yds. ❑ bags
C�� tr�� ��t wy� A� NEARES � SQURCE OF CONT INATIOfy_ L/
er-•- ���� 1 feet 'i.J I rf �� � ��
direction type
Well disinfected upon completion? L9 Yes ❑ No
Gr8Ve1 tffi1 SOfC lOC} 120
PUMP
Ci $�a �1 t �4� 155 � Not installed Date installed ��7��
� � l Manufacturer's name _�Q�,t.�� �f�n
Model number HP� Volts L..7t!
.�`il� �$V .�,�t 1,rj5 �7� Lengih of drop pipe �S ft. Capaciry �R g.p.m.
l
Pressure Tank Capacity yC.���1
Cilgy �a� �it 175 195 Type: � Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
G`�1 �pll� �f t 195 ,W7 Does property have any not in use and not sealed well(s)? ❑ Yes L9 No
.7"
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes L�No
WELL CONTRACTOR CERTIFICATION
Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is hue ro the best of my knowledge.
ao� st«�oi$ r��i �3zZ�; co., n�. Zn�z
Licen ee Business Name Lic.or Reg.No.
_�;;r ,�...�;r��� �-L�-�s�
Authorized Representative Signature Date
Fred �eiby
Name of Driller HE 01205-OS(Rev.1/95)
LOCAL COPY � ( � � '�O
i �
Jivin �itr� UVater ��ircic, �nc.
61713th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556
o7r��lsss
Stodola Well Drilling
15306 Hwy 7
Minnetonka MN 55345
938-2111
REPORT OF WATER ANALYSI5
Lab#: 30301
Our Laboratory reports these analytical results, determined on a sample taken
by CLIENT on 07/15/1996 from the following location:
Keith 1Mater 8 Assoc.
2320 Longview Circle
Orono�Mn
Unique 1Ma11 N573600
Coliform Bacteria <1N00 mi
Nitrates Nitrogen <1.0 mgn
The results of these tests indicate that this well is producing water that meets the standards for
F.H.A., V.A., or conventional loans. This report is an analysis for coliform and nitrate only and
�\
oes not inGude analysis of Lead and other contaminants. (Unless as specified by clier�t).
'n i Clini , Inc.
Bill e
��r �s�
wa��o.�w xe�r. sou«w.�«cn�
Lab Cert�iation�02'I-033-119