11/08/18 Well and Boring Sealing Record

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, , - MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD 44 D Minnesota Statutes,chapter 1031 8 3 9 614 Township Name Tt unship No. Range No. Section No. Fraction(sm.—Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 06 SS::8E1/4SW"s 210 it 1-9-19 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD ir Latitude Longitude ❑Cable Tool Xis/en ❑Dual Rotary ❑Auger otary ❑Rotasonic House Number,StreetName,City,and ZIP Code`�{1W►ell Location +� ❑Other / 780 Lakeview Parkway, Orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes IJFNo beShow exact location of well/boring in section grid with" " Sketch map of well/boring location. jte T Showing property lines, From ft.To ft. r ads,buildings,and direction. USESo ❑Monitoring ❑Heating/Cooling MI1111111 J ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial BINEIll O CommunityvatoPWS ❑Irrigatteri ❑Remedial ❑Elevator Dewatering❑ ,,��SS❑ wBINEI E • CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. Steel ❑Threaded ❑ elded �� Plastic ❑ CASINGm Diameter Weight Specifications I 1 Mile "�' p �✓ in.To ft. lbs./ft. �_in.To, t. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. bs./ft. in.To_ 01. Norton s n.To ft. lbs./ft. in.To ft. OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN Johnson }18215 45th AVe Nil Ste D Make stainless steel From 2" ftL.Type Diam. To ft. Pl�th, MN 55446 Slot/Gauze .010 Length 41 + 4* Set between 200 ft.and 210 ft. FITTINGS 21I 1entitar STATIC WATER LEVEL" 75 ft. Below ❑Above land surface Date measured 1- -19 Dry hole ❑Yes No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 195 ft.after 5 hrs.pumping 35 q.p.m. Well/boring owner's mailing address if different than property owners address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer Tildieftwatar Model ❑Casing protection /12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material bentonitfrom 0 To 50 ft. 3 ❑Yds./Bags Material cutting FromTo—liar ft. ❑Yds. Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement or 50 lbs.bentonite medium KNOWN SOURCE OF CONTAMINATION — m Clay brawn edium 0 15 Well is 4/:—.7— ( .',.z�''t9Pe 15 feet direction from clay gray medium 55 Well disinfected upon completion? X Yes ❑No •— • '>.& clay/sand graysoft]a55+ 70 62 PUMP sandy clay gray medium 62 ❑Not installed Date installed -19 sped/gray el mix soft 9070 90 Manufacturer's name Schaefer fine sand brown brown soft174 Model Number HP 4 1.5 Volts 230 silty clay/sand174 brown medium 199 Length of drop pipe 105 ft. Capacity g.p.m sand/gravel mix soft 199 210 Type: Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABA ONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes;ONo VARIANCE 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. 6-17-19 °-°:-,Ze: erti epr sentative Sig(ature Certified Rep.No. Date Rob Stodola LOCAL COPY 8 3 9 614 Name of Driller ID#52603 HE-01205-17(Rev.5/17)