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MINNESOTA UNIQUE WELL <br /> WELL OR PORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name . WELL AND BORING CONSTRUCTION RECORD 8 3 9 5 8 6 <br /> Minnesota Statutes,chapter 1031 <br /> Township Name Township No. Range No. Section No.., Fraction(sm.—.Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 23 23 NW M NW ,' 129 n. 8-17-19 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude C Cable Tool ❑Driven _ ❑Dual Rotary <br /> ❑Auger N�j Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> 750 Big Island, Orono <br /> 55331 DRILLING <br /> GFFLUID'r WELL HYDROFRACTURED? ❑Yes SiNo <br /> Show exact location of well/boringin sectiongrid with"X." Sketc mapof well/b rin los ion. bentonite " '` <br /> $t�J�6�Qrog9e ��jue� From ft.To ft. <br /> a 14c- imdsi l�tlildWnT�s,9nd di ectiolr USE <br /> N ]Domestic ❑Monitoring ❑Heating/Cooling <br /> _________________________ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> •1 <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> ---=--------- , ' ❑Elevator ❑Dewatering ❑ <br /> w E CASING MATERIAL Drive Shoe? ❑Yes , No HOLE DIAM. <br /> El Steel ❑Threaded ❑Welded <br /> ,h Mile <br /> Plastic ❑ <br /> rs 1 - <br /> CASING <br /> ////7.. Diameter Weight Specifications <br /> 4 1 Mile- { \ in.To 120 ft. lbs./ft. 8 in.To50 ft. <br /> •• PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. bs./ft. in.Tot ft. <br /> Terry D orf in.To ft. lbs./ft. n.To ft. <br /> L SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. ThnionMake � <br /> 10575 Robinaoc3 Dr NW Type eta1A steel From ft. <br /> 2 ft. To ft. <br /> /�.'_�r �{ y+� stain.less t� <br /> Coon Rapids, MN 55433 Slot/Gauze .15 Length qV + 4$ <br /> Set between 120 ft.and 129 ft. FITTINGS mat leader <br /> STATIC WATER LEVEL 42 ft.xi Below ❑Above land}surface <br /> 8 Date measured 4749 Dry hole ❑Yes yiNo <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 115 ft.after_ 2 _ hrs.pumping g.p.m. <br /> Well/boring owners mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> ❑Pitless/adapter manufacturer Model <br /> ❑Casing protection Xr2 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump Sanitgry Seal <br /> GROUT INFORMATION(specify bentonite,cement-sand,-sanneat-cement concrete,cuttings,or other) <br /> Material bentonite From 500 To'f X50 ft. 3 ❑Yds. Bags <br /> Material cuttings From To120 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 /> One bag94 lbs.cement <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay <br /> brown medium 027 Well is //. , feet direction from ‘,--) type <br /> -*- � Well disinfected upon completion? Yes ❑No <br /> y gray � 27 102 PUMP <br /> LINot installed Date installed 8-1.7-19 <br /> clay/gravel gray medium 102 115 <br /> Manufacturer's name <br /> sand gray soft 115 130ill Model Number HP 1/2 Volts 230 <br /> Length of drop pipe 80 ft. Capacity g.p.m <br /> Type'Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes l- No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes lei 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. Don Stodola Well Drilling Co •"IT nc. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> '` / 9-5-19 <br /> J G <br /> !-rtrled`epresentati•- .nature Certified Rep.No. Date ' <br /> LOCAL COPY 8 3 9 5 8 6 Name of Driller Rob Stodola <br /> ID#52603 HE-01205-17(Rev.5/17) <br />