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b1�LL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO.
County Name WELL AND BORING RECORD 6 5 5 0 2 0
Minnesota Statutes Chapter f03/
Township Nam Township No. Range No. Section No. Fraction WELL DEPTH(completed). Date Work Completed
_ , . ... . '..h:�
i. /. v.
House mber. treet Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD
❑ Cable Tool ❑ Driven ❑ Dug
❑ Auger ,�Rotary G Jetted
Show exact locatio of well in section gri with"X". Sketch map of well location. Cl _
Showing property lines,
� roads and b ildings. DRILLING FLUID WELL HYDROFRACTURED? [�VES�'NO
� q`R N \_
� water
i. i � i i � FROM ft.to ft.
i -�- -�- -� - -�- -��' USE ❑ Monitoring ❑ Heating/Cooling
' � � i i Domestic ❑ Communi PWS
( _i_ _�_ _�_ _i_ X �� ❑ Irrigation Ty ❑ Industry/Commercial
i i i i C7 ❑ Noncommunity PWS ❑ Remedial
! w e T � ❑ Environ.Bore Hole ❑ Dewatering ❑
; i i i i I -
r -r -7- -r- -r \
' i i i i +/ZM e ,}� CASWG Drive Shoe? ❑ Yes �No HOLE DIAM.
_i_ _ i_ _L_ _i_ � \,j ❑ Steel ❑ Threaded ❑ Welded
� � � � �Plastic ❑
S
�1 Mile�
CASING DIAMETER WEIGHT
1 PROPEF3TY OWNER'S NAME t�. in.to�_p�Z ft. __ 2.{js Ibs./ft. �in.to_��
_in.to__ ft ._ Ibs./R (�� in.to�lf
' S-
j Property owner's mailing address if different than well location address indicated above. __in.to ft. _ .___IbsJft. in.to ft.
�, �) v� SCREENT�.� OPEN HOLE
'f� E Lake �t Make v��lil+'f�n
from fl.ro ft.
t�ayzata, MN 55391 Type�ia_inle�s steel Diam.
SbUGauze �/11�1 Length �• ,� J. � „
Y
Set between __�ft.and it. FITTINGS:
STA IC WATER LEVEL
WELL OWNER'S NAME �1� ft.�'below ❑ above land surface Date measured in—z�i� Q
PUMPING LEVEL(below land surface)q
Well owner's mailing address if different than property owner's address indicated above. _1 7� ft. after G hrs.pumping�.Q__ g.p.m.
WELL HEAD COMPLETION �y,�j �,� a.
�Pitless adapter manufacturer e�il1 yQS�e�.y���___ Model _,___ __ G
- ❑ Casing Protedion___ _ _�] 12 in.above grade
❑ At-grade(Environmental Wells and Borings ONLY)
GROUTING INFOFMATION
Wellgrouted? �Yes ❑ No
GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Materia� ❑ Neat cement ❑ Bentonite ❑ Concrete �High Solids Bentonite
MATERIAL from 0_ to�Q ft. 2.5 ❑ yds.� bags
from�_to�__h�a t�.r$�_��7�yis. L7 bags
Clay Z'$ $Q�t O from to ft ❑ yds. ❑ bags
NEAREST KNOWN SOURCE OF CONTAMINATION e-- �
Sand r8 gOf� t�0 1z ���— _feet ��Gr� z' directiotA.��type
Well disinfected upon completion? �Yes ❑ No
CI$y broRn .4�1t i4Q 18 PUMP
�, Not��5�a��ed Date installed 1-16-0 I
Sand r$ S(�f� 80 Manutacturer's name _Aermntor
Model numberT�50 _. ___ _ HP 1 .5 va�s_2 30 _
Length of drop pipe 14$� __ ft. Capacity __�g.p.m.
Type: LJebubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet
ABANDONED WELLS
Does propeRy have any not in use and not sealed well(s)? ❑ Yes �No
VARIANCE
. Was a variance granted from the MDH for this well? ❑ Yes �fJo TN# _
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WELL CONTRACTOR CERTIFICATION
Use a second sheet,il needed 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 ot my knowledge.
REMARKS,ELEVATION,SOURCE OF DATA,etc.
D�� _Stodola We11 Drj,_t 1 ino � �j� �
Lic see Busin s Nam �or eg. o.
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�„�,- ,.-.
1-26-01
Authorized R sentative ignature Date
_ nt►k Mnnr�g 1 t1.�9l4_.rtn
6 5 5 0 2 0 Name of Driller ' Date
LOCAL COPY HE-01205-07(Rev.2/99)
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� � Tw i�vv C i,t litl at�' C ' ' , .I vu'i.
y
617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556
l 0/26/2000
Stodola Well Drilling
3841 Norih Main
St. Boni facius MN 55375
938-21 1 1
REPORT OF WATER ANALYSIS
Lab#: 521
Our Laboratory reports ihese analytical results, deCermined on a s�mple taken
by CLIENT on T O/24/2000 from the following locarion:
Lauer Homes
1250 Lyman Ave.
Wayzata,Mn
Unique Well#655020
Coliform Bacteria <1/100 ml
Nitrates Nitrogen <1.0 mg/1
The results of ihese tests indicaie thai ihis well is producing water thar meets the
standards for F.H.A., V.A., or conventional loans. This reporr is an analysis for
coliform and niirate only and does not include analysis of Lead and other .
conraminanis. (Unless as speci�ed by client).
�` ir W er Clinic, Inc.
��
Bill�V a e
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Lab Certification H 027-053-119