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WATER ANALYSIS
7608 119th Lane North • Champlin, Minnesota 55316
Telephone: 427-0826 4 id o v e 1n b e T' 1 y o 7
Approved
Minnesota State Board of Health, Bacteriological Laboratory 42788-000 ,
TFST N0: 397b7
Wisconsin Dept. of Health & Social Services Licensed Laboratory TIt•7E: 11 • �0 a.m.
FED. ID #411443773 '
PP,OT-1: 4de11 434286
Ta : 45�30�HIGHLANDOPOAD D � �"�' -�..���'`I�
?�1It�;��1ETOtdI�A, I��IPI. 55345 �
-----�-. ��� � � � �
Re : t�'�ter test t : �520 i`1 S.iore Dr , , rono, P�1n
David Sin�e
Gentlemen :
Field Engineerin� or their authorized personnel dreca
and tested the water at the above address on 3 November 1967
and the results were as follows :
Nitrate I�itroben-per Cadmium Reduction rlethod- U. 5 mb/1
(P�Iaximum allowable limits, less than 10.0 mg/1)
Coliform Bacteria-per U. S. P. H.S. MF Aiethod 0 per 100 ml
(2�Saximum allowable limits, less than 1 per 100 ml)
`Chis �aater DOES meet FHA, VA , and U. S. P.FI. S specifications .
Field En;ineering, Inc, is authorized to perform these tests
by the tlinnesota Environmental Health Division , tJell Department.
Sincerely Yours ,
/ �
�.����-�`��%'���
i�3arvin J . ��denzel
Detach belo�a and return with payment
STATC(�MINNE50TA UYJ'ARTMCNT UY IICALTII
WATER WELL RECORO w/NNESOTA UNIpUL W6LL NU.
Coun�y N�mr /�r W�M Syfi
Mi��as4 SLhb 136A.01�.0!
Townahip Namr' o�vnship Number Ranyt NumCer $cccion Na Fraction �.WELL DEPTH(mmpleledl tt d an wn
� a �4 '4 '4
W Il.
U�urrr and U.ectan fran Rdd In�rrsertan or S�reN Address and City d Wdl laa��on S.DRILUNG METHOD
10 GWe�ool �O Revene 70 Drivm IU�Du�
W ruc�locsiun i1 W�II in sectnn Qnd rich"X." Sknch maD y'dl �ion. 2C7 Hdlm.�rod 50 Air BO Bored I10
N
� i Addi�ion Namr :10 Raary 60 Jelled 90 Po�vv'ruQer
"�" T _a _L_
6. DRILUNG iLUID
i : �
._�_ _1_ _ � lock umbrr 7. USE
w � E
-1- -1- '�- -- T IODomestic �OMmitorin` 80Hu�Pump
� I � � Ld Num6er 20IrriQstion SO PuWic 90lnduury
�"". 37 Tnl Wdl 6O Municiql 1C0 Commercul
-�- �- - -r- I 70AirCondilioninQ 110
1
� i �� 8.CASING HOLE DIAM.
HEIGHT:A6ow&Im.�
2. YROYE�WN� 10 B4ck �p Throded
< / SuAaa It.
s�� ��� 20 Galv. SO Welded p��r Shu? Yn_ N�_
�ee.R. 3 �R,�u� sa
�� �?J�'L�,��/ �e.to n. wr�m �hc.�n. _;a �u_Jt.
7. FORMATION LOG COIOR HARDNE55 t ��M TO in.to 1�. Wtiaht IOa./It. _ia �o_J�.
FORMATION
in.to f�. WeiQht Iha./h. �n. ta_lt.
9.SCREEN O��open hok
Irom (�.�a (t.
Make
TY� Di�.
Sla/Gauu�� �^���
r ^ C/ _ � .. FfTTINGS�.
$el helWKn Il.�I1d II.
� ;� 10. STATIC M�ATER LEVEL
It.O 6elo�r O a6ovr Due Mosured
land suAace
�/ I I.PUMPING IEVEL(heb�r brd sur(aal
',4,j"_
/l�✓v �• / � It.iller hn.pumpr� �.p.m.
It.iller hrc.pumpnQ Q.p.m.
12. HEAD WELL COMPLETION
� 10 Pi�kst sdaper.manu(atturv mada�
. 20 Bacemm�dl�e� JO M kui IT"above arourd
10 Plastic psinQ praection
C�� 13.WELLGROUTED�
�� o� ��
e,i cemmi zO&n�miu 70
Grout matetil Irom w It.cv.ydt
—3�:- r, �,
- � -� �'!�_ J
� _ . __ .___�,
'�i I !� I!.NEAREST SOURCfS OF POSSIBIE CONTAMINATION
� ...� • feet dirtction tYD�
Well di�inlectd upon mmp4tiont O Ya O No
I5. PllMP
Due inaulkd O Nd insultad
Manu(acturer'�name
Model numM HP Vdt�
lenpth d droD PLY 1�. o{ucity I.p.m.
Matni�l d drop ppt
Type:10 Suhmerubk �L5.Turbine SO RedRoacinQ
201et 10 Centrifu;al 60
I6. EXISTING WEL1.5
Unu�ed We11 m property.' O Yn O No
Uv a uro+J�M.�t.i/.rrded A6�ndaxd O Permanenl O Temporary O Na uakd
I7. ftEMARKS.ELEVATION,SOURCE OF DATA,ecc.
• I8. WATER WELL COHTRACTORS CERTffICATION
This Wdl�va�dril4d uider my jundictim�nd this repat is true to the hnt d my
kro�rledQt ud 6elid. �
/�c��i�T E'" sP`o_� ` L .sc .�7✓'1 4.
Lirtwut B�ui�ar Nnwr Lirnav No.
,,�.K. Y�r 3 0 ���d c..�-d �c+ r-r�-,E•.a,
5�snd /L �./`Z �Z�T+^r^ �-t . � :��..y-
Authorired Repn+en4tive
l�aa ,�'�'4�t �c r� � ��"-• `�
r+.m��r o����.
s��.aou
WORK COPY �����
�,,.�.,
HEOI20S02(Rev.IW35) Ziu tpy
STATE OF MINNESOTA DEPARTMENT OF HEALTH
WATER WELL RECORD M/NNESOTA UNfQUE WELL NO. A `� /� � O C
Caunt Name , �- �
Y dH��ro srorwra tsea.oi�.os fo.war�.saMp�e F J � t� V
Townahip Name� , ownship Number Range Num6er Section No. fraction 4.WELL DEP"fH(compkted� Dare of Completion
N E � ,� �b �� J
.. - . . -Sf °r `y aX� � ft. �' �� �� � l
Distance and Direction(rom Road(ntersection or Street Address and City of Well Location 5.DRILLING METHOD
lO Cable tool 40 Reverse 7p Driven !00 Dug
ow exact location d well in section grid with"X." Sketch map of well laation. 2O Hollow rod 50 Air 8C]Bored 11O
N
� � � i Addition Name ;i�e Ro[ary 6O Jetted 9O Power�auger
--r- t -i 1- 6.DRILLINGFLUID
� ' i i
W •-i- -;- ;- �- E lock Number 7. USE
_1_ _1_ _'_ S_ T '4�7 Domestic 40 Monitonng 8C]Hea[Pump
I i � �' Lot Number 20lrrigation SO Public 9�Industry
' f mi.
� � i I 3�Test Well 6�Municipal IOO Commercial
'-�- �- - -�" 1 7L7AirConditioning IIO -
t
H—����t 8.CASING HOLE DIAM.
2.PROPERTY OWNER'S NAME HEIGHT:Above/Below
lO Black dO Threadcd
- Surface ft.
2O Galv. $p Welded
Address � � . ' � - Drive Shce? Yes—No—
3Q Plastic 6p
. `� in.to � tt. Weight Ibs./(t. _�n. to_ft.
3. FORMATION LOG COLOR HARDNESS OF FROM TO in.to tt. Weight IbsJ(t. —in. to—ft.
FORMATION
in.to ft. Weight Ibs./ft. �n. to-�t.
' �.�f 9.SCREEN Or�open hole
from (t.to. tt.
Make
� . .�.Yce . . -.. Dis. �
SbVGauze L¢ngth �= -
F17"f[NGS:
Set between ft.and it.
10. STAT[C WATER LEVEL
tL O below ❑above Date Measured � ,f
land surface
11. PUMPING LEVEL(6elow iand surtace)
3 .
- ft.after hrs.pumping ' g.p.m.
f[.after hrs.pumping g.p.m.
' L' � 12.HEAD WELL COMPLETION ,,,-
, � '� �. t�Pidess adapter.manufacturer � � model _
�
2O Basement offset 3O At leas[12"above ground
4O Plastic casmg protection
13.WELL GROUTED?
4 Yes ❑No
lONeat Cement 2C]Bentonite 3O
Grout material trom to,�,�_ft.cu.yds.
14. NEAREST SOURCES OF POSSIBLE CONTAMINATION
� feet - direction ' type
Well disintected upon rnmpletion? O Yes ❑No
15.PUMP
Date installed ❑Not installed
- Manutacturer's name ~
Model number " HP Volts �
Length of diop pipe ft. capacity g.p.m. 'k
Material ot drop pipe �
Type:.dp Submersible 3O L.S.Turbine 5O Reciprocating
2�Jet 40 Centrifugal 6O
16. EXISTING WELLS
Unused well on property? j�57,yes ❑No
Use a second shee(,if needed
17. REMARKS,EIEVATION,SOURCE OF DATA,etc. Abandoned � Permanent❑ Temporary❑ Not seakd
• 18.WATER WELL CONTRACTORS CERTIFICATION
This well was drilled under my jurisdiction and this report is true to the best ot my
knowledge and beliet.
Licensee Business Name License No.
Address '� � �
i
i '
' Signed � - Da[r '�/� ,�
� - Authorized Representative
;�l � . . _... .. _.. Date % .. :j� .7 .
-Name of Driller
S/74 30M
7/76 30M
�o��� ���� 4 3 4 2 8 6 „�B�
HE�01205�02(Rev.10/85) p���q„�