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` MINNESOTA UNIQUE WELL <br /> WE R BA"ING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County.Name WELL AND BORING RECORD <br /> vTennE' in Minnesota Statutes,Chapter 1037 8,94574 <br /> Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COKQLETED <br /> Orono 117 23 1 08 NE ;?? 'TF,, 0 ft _31_ CEJVED <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds LOCATION: <br /> Longitude degrees minutes seconds ❑Cable Tool Driven _ 32015 <br /> El Auger Rotary I <br /> House Number,Street Name,City,and ZIP Code of Well Location Ll Other <br /> 1170 ton"wa Rd, Drono 55356 DRILLING FLUID WELLHYDRURIHCSUfj aY�s No <br /> Show exact location of well/boring in section grid with'X:' Sketch map of well/boring location. 1(ntonjte From �� t i ft.To K NO ft. <br /> E Showing property lines, <br /> N ++ roads,buildings,and direction. USE F1Domestic ❑Monitoring ❑Heating/Cooling <br /> :_____–_____:_____t__ Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> i -- ---------t-- �–^ '� ❑Elevator ❑Dewatering ❑ <br /> W ET i CASING MATERIAL Drive Shoe? [_1 Yes No HOLE DIAM. <br /> - -- ---------: <br /> i <br /> ❑Steel ❑Threaded ❑Welded <br /> 'h Mile <br /> a: Plastic ❑ <br /> CASING <br /> S f Diameter L Weight Specifications <br /> 1 Mile 4 in.To 161 ft. lbs./ft. �in.To 5(4t <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. 6 4 in.To 17`-1t <br /> Cha s Codd T)e ATovo' LWin.To ft. lbs./ft. in.To _ft <br /> Property <br /> �owner's mailing address if different than well location address indicated above. <br /> SCREEN OPEN HOLE <br /> 15,15 23rd AVe :�s <br /> Make nson From - ft. To ft. <br /> e{� Type stainlessteel Diam. <br /> Plymouth, ?':, 55447 Slot/Gauze _010 Length 41 ♦ 41 <br /> Set betweeni <br /> ft.and ft. FITTINGS M <br /> STATIC WATER LEVEL <br /> Measured from50 — — <br /> ft.X Below ❑Above land surface Date measured <br /> WELL OWNER'S NAME/COMPANY NAME - PUMPING LEVEL(below land surface) <br /> 158 ft.after 4 hrs.pumping 40 g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION „� a tT�te r <br /> Pitless/adapter manufacturer wt LL Model <br /> Casing protection X 12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material bentonite From To�ft. 3 ❑Yds. lags <br /> Material natural f trinl__50_To 16 ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From-To-ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From TO _Bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ssnly cls, 1)rotm medlum n t�7 1! feet .......type <br /> ��. direction �., - <br /> �.;.,-.. <br /> Well disinfected upon completion? Yes ❑No <br /> St?< k+L "Jt1 Soft 17 62 PUMP <br /> ❑Not installed Date installed 4-7-15 <br /> Cla /sand J,rn milium 62 $8 Manufacturer's name Scharer <br /> Model Number HP- 2 Volts <br /> sand hrocim soft �r 17C1 <br /> Length of drop pipe 126 ft. Capacity g.p.m <br /> Type:X <br /> Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANCIONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No TN# <br /> WELL CONTRACTOR CERTIFICATION <br /> This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> The information contained in this report is true to the best of my knowledge. <br /> Use a second sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> itodola Itiell nrillin Co <br /> Licensee Business <br /> Name Lic.or Reg.No. <br /> f~ 7-28-15 <br /> ,Certified Representative Signature Certified Rep.No. Date <br /> $tab Stodola <br /> LOCAL COPY Name of Driller <br /> IC 140-0020 HE-01205-14(Rev.5/12) <br />