Well and Boring, Sealing Constsruction Record

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TA UNIQ WELL 019 BORING'LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN ES AND BORING NO.WELL County Name WELL AND BORING CONSTRUCTION RECORD 8 2 6 6 5 3 Hennep Minnesota Statutes,Chapter 1031 Township Name Township No. Range No. Section No. Fraction(sm.–.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 09 SE NWy,SW V. 290 n. 12-21-17 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude . ❑Cable Tool ❑Driven ❑Dual Rotary ❑Auger ig Rotary i ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑Other -` 3017 Nori-k Shore Dr, orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes,gNo Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. bentonite From ft.To ft. Showing property lines, N 4 Koads,builipack and direction. USE 24 Domestic ❑Monitoring ❑Heating/Cooling JJ1-1-1 1 --`rte Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial , Community PWS ❑Irrigation ❑Remedial ---4---.4-----;______;--- ,. ❑Elevator Dewatering w E T CASING MATERIAL Drive Shoe? y—lZYes ❑N o HOLE DIAM. -t-- -;- 1-- --F- I Steel Threaded' ❑Welded kMile ❑Plastic 0 : 1 t ..NN, CASING 3 wn \\ Diameter Weight Specifications 1-----1 Mile -41----0-1-0 245 ft. lbs./ft. in.To_ t. i PROPERTY OWNER'S NAME/COMPANY NAMEin.To ft. lbs./ft. lTo 726.Swanson Homes n.To ft. lbs./OPEN HOLE ft. /en.�To�90t. Property owner's mailing address if different than well location address indicated above. SCREEN 1360 Hamel Rd Make From '245 ft. To '99fl ft. 136, 1 g Type Diam. Medina, MN 55340 Slot/Gauze Length Set between ft.and ft. FITTINGS STATIC WATER LEVEL 35 ft.❑Below,,Above land surface Measured frontOp of gel-tate measured 12-21-17 Dry hole ❑Yes/ No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 165 ft.after 5 hrs.pumping 50 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Whitewater Pitless/adapter manufacturer Model ❑Casing protection 2 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material benton Brom 0 To 5pft. 3 ❑Yds.SI Bags Material From To ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One ba 94 lbs.cement Driven casing seal From 231 To 245 Bags g or 50 lbs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION ([ topsoil black soft 0 4 Well is 2ail feet 4/ direction from n' i ; 4-3 • t .- 'r type.� Well disinfected upon completion? xYes ❑No /�t_�_, C.$3,k e� clay/sand gray soft 4 36 PUMP r ❑Not installed Date installed 9-8-18 .1 • . '.• • Manufacturer's name Schaefer �n Model Number HP1.5 Volts 230 sand/clay gray um 162 226 Length of drop pipe 63 ft. Capacity g.p.m shale/sandstone yellow snft 226 245 Type:DC Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ y ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes 'No sandstone/shale white/ mw'dtum/ / VARIANCE hard' rd 245 290 Was a variance granted from the MDH for this well? ❑Yes'No TN# _ WELL CONTRACTOR CERTIFICATION 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 of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodola Well Drilling Co,. Inc. 1691 Licensee Business Name Lic.or Reg.No. 9-27-18 --er,'_. eprese &( �nature Certified Rep.No. Date LOCAL COPY 8 2 6 6 5 3 Name of Driller w ' .. ID#52603 FIE-01205-1601.m5/16)