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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
'� CountyName WELL AND BORING RECORD 6 5 5 0 4 6
Hennepin Minnesota Statutes Chapter f03!
Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed
fl.
Orono 118 23 35 ,. ,. ,. I30 1Z-1-00
House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
1151J 7i.r �Sn xd Orono ❑ CableTool ❑ Driven i7 Dug �
CJ Auger �l Rotary i.7 Jetted
Show exact location of well in section grid with"X". Sketch map of well location. ❑
---. ..._ ------ ----..—...----
Showing property lines,
�� roads and buildings. DRILLING FLUID WELL HYDROFRACTURED? ❑YES �O
kN
� � � , � � wa t e r FROM_ n.to K.
� -; -;- -r- -,-
USE ❑ Monitoring ❑ Heating/Cooling
1 _i_ _�_ _i_ _i_ .�,��_ � Domestic ❑ Community PWS ❑ Industry/Commercial
F. i i i i � ❑ Irrigation ❑ Noncommunit PWS
w E Q o ❑ Environ.Bore Hole Y ❑ Remedial
' i � i i x ❑ Dewatering ❑
�� i i i -r I � CASING Drive Shoe?
'/2M1e ❑ Yes L7 No HOLE DIAM.
_i _i_ _�_ _i_ I � ❑ Steel ❑ Threaded ❑ Welded
r � � � 1
y p Plastic ❑
S
�1 Mile�
CASING DIAMETER WEIGHT
PROPERTY OWNER'S NAME ��in.to��__e. _�,_r1� Ibs./tt. �_in.to�ft.
J�S H�1Qe$ -----in.to-- _ _ ft. IbsJR �in td�_�ft.
Property owner's mailing address if different than well loca[ion address indicated above. _—. in.to_ __ _ ___ft. Ibs./ft. in.to ft.
`�Q � 79ti1 St � S�e 133 SCREEN_ OPENHOLE
�►a�hass�en, MN 55317 Make_Johns��__ from ft.to ft.
TYPe�i-a���-C-�-�—�����s�—Diam. ?N —
SIoUGauze A�n ______Length _
•
Set between ft.and it. FITTING �
STATIC WATER LEVEL
WELL OWNER'S NAME b� ft.Ts�below ❑ above land surface Date measured�t—�_nQ
PUMPING LEVEL(below land surface)
Well owner's mailing address if diflerent than property owner's address indicated above. __�1 g _ft, after__L. ._,_ __ ____hrs.pumping_ � g.p.m.
WELL HEAD COMPLETION
�Pitless adapter man�i�e��_�����r _ Model ___.
❑ Casing Protection_ _ _ __. _ ___ p 12 in.above grade
Cl At-grade(Environmental Wells and Borings ONLY) �
GROUTING INFORMATION
Well grouted? �'l Yes ❑ No
� GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material r� Neat cement ❑ Bentonite 'i Concrete ❑ High Solids Bentonite
MATERIAL from Q _to__ .��t. ���__ ❑ yds ❑ bags
from�,--_-to—��_"�t. �$�i+�Biy�.�7 bags
(�+1a from _ __to _ft. _. _______ ❑ yds. ❑ bags �:
NEAREST KNOWN SOURCE OF CONTAMINATION �
� teet
C�$ _��__— .��,��direction �����Rqpe
Well disinfected upon wmpletion? '�] Yes ❑ No
sand PUMP
- C] Notinstalled Dateinstalled__.__._ �_������ ��
Manufacturer'sname �Q�'}Q��Qj'_ _ _ `
�� Model number_. ._._ _ __ . , _ __ _,. __,_ HP . . _ Volts__�q-9��� -
..����-- G3V —
Lengthotdroppipe.___S!L__ _ ft. Capacity ____ ___g.p.m.
p�}
Type: Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed well(s)? ❑ Yes ,�No
VARIANCE
Was a variance granted from the MDH for this well? u Yes I�lo TN# -
WELL CONTRACTOR CERTIFICATION
Use a second sheet,i/needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725.
REMARKS,ELEVATION,SOURCE OF DATA,etc. 7he information contained in this report is true to the best of my knowledge.
D�n—�31-L1�ii►e�ess��Na e—�s—�"Lic ora�`ey�No��_ �� 72
��_�
3-27-42
�Authorize Repr nt iv S nature� Date
Chuek Moore 12-1-00
6 5 5 0 4 6 Name ol Driller Date
LOCRL COPY HE-01205-07(Rev.2/99)
V � Twi�vv Ci,t� l�tl at"e�r�' C ' ' , I�►,c�
y
617 13th Ave So � Hopkins, Minnesota 55343 • (612) 935 - 3556
12/OS/2000
Stodola Well Drilling
3841 North Main
St. Bonifacius MN 55375
938-21 l 1
REPORT OF WATER ANALYSIS
Lab#: 690
Our Laboratory reporrs these analytical results, determined on a sample taken
by CLIENT on 12/04/2000 from rhe following locaiion:
JMS Homes
1150 Lyman Rd.
Orono,Mn
Unique Well#655046
�
Coli form Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/1
The results of these tests indicate rhat ihis well is producing water thai meeis 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 f_�ad and other
contaminants. (Unless as specified by client).
' Cify ater Clinic, Inc.
\ �
Bill sd e
Lab Certification tt 027-053-119