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' MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD 8 2 7 8 2 9 <br /> �� Minnesota Statutes,Chapter 1031 <br /> TowFnisFee��ip-Nae in Township No. Range No. Section No. Fraction(sm.--.Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 28 10` NE ISI£. NE ' 123 11. 12-16-18 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude 4 ❑Cable Tool - ❑Driven ❑Dual Rotary <br /> ❑Auger s3' Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> 980 Heritage Lane, orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes X.No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. bentonite From ft.To ft. <br /> gs properly lines, <br /> N oads,buildi .s,and direction. USE Domestic ❑Monitoring ❑Heating/Cooling <br /> 7 ':- <br /> ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> ' • . _off'— ❑Elevator ❑Dewatering ❑ <br /> w' E T /1" VVW�� CASING MATERIAL ❑ HOLE DIAM. <br /> Drive Shoe? Yes o <br /> ❑Steel ❑Threaded ❑Welded <br /> Mile v RPIastic 111 <br /> r s 1 CASING <br /> Diameter Weight Specifications <br /> O' p� <br /> ) 1 Mae { $ 4 in.To 119t. lbs./ft. 8_in.To 50 ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. bs./ft. Z n.To125 ft. <br /> in.To ft. lbs./ft. in.To ft. <br /> Tom Potter Construction t,_ OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. SCREEN <br /> Johnson <br /> Make From +� ft. To ft. <br /> 6531 Devonshire Dr Type stainless steel Diar1F.T <br /> Chanhassen, MN 55317 Slot/Gauze .010 Length' + 4' <br /> Set between 11 ft.and 123 " ft. FITTINGS 2"x8' leader <br /> STATIC WATER LE L 60 ft.Oelow ❑Above land surface <br /> Measured from top of WPLle measured7—�6-18 ry hole ❑Yes j 10 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 110 ft.after 2 hrs.pumping q.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> XPitless/adapter manufacturer Whi tPWP1 tPr Model <br /> ❑Casing protection jig in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material bentonit °m 0 To 50 ft. 3 ❑Yds. iNt9ags <br /> Material cut tings From 50 To 115 ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From Jil To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement <br /> or 50 lbs.bentonite <br /> course gravel/ t, 8 NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay brown medium 0Well is 1<CJ feet Al direction from 452-p _-c__ type <br /> Well disinfected upon completion? Wes ❑No <br /> sandy clay brown medium 8 32 PUMP <br /> ❑Not installed Date installed 4-21-19 <br /> clay gray medium 32 83 Manufacturer's name Schaefer <br /> p Model Number HP 1•5 Volts 230 _ <br /> sand/gravel mix medium 83 100 84 <br /> Length of drop pipe ft. Capacity g.p.m <br /> CIS red soft 100 11 3 <br /> Type: ubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet Ely ABANDONED WELLS <br /> sand/gravel mix medium 113 125 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,it needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Don Stodola Well Drilling Co. ,Inc. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> 4-25-19 <br /> C ie esgfi ive . n ur Certified Rep.No. Date <br /> r.. <br /> LOCAL COPY 827829r,.� eo...�-1— <br /> Name of Driller <br /> ID#52603 HE-01205-16(Rev.5/161 <br />