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ee1e1e1c¢n7n r mint 1C IAre1 r <br />WELL OR BORING LOCATION <br />" <br />MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br />WELL AND BORING CONSTRUCTION RECORD 839622 <br />Minnesota Statutes, chapter 1037 <br />County Name <br />Henn in <br />Township Name <br />Township No. <br />Range No. <br />Section No. <br />(sm. —. Ig.) <br />WELLBORING DEPTH (completed) <br />DATE WORK COMPLETED <br />Bran <br />117 <br />1 23 <br />]Fraction <br />16 <br />% NW NW NGTit] <br />110 <br />8-7-19 <br />GPS LOCATION —decimal degrees (to four decimal places). <br />DRILLING METHOD <br />Latitude Longitude <br />❑ Cable Tool ❑ Driven ❑ Dual Rotary <br />❑ Auger WRotary ❑ Rotasonic <br />❑ Other <br />House Number, Street Name, City, and ZIP Code of Well Location f <br />1.600 Bohns Point Rd. Orono 55391 <br />DRILLING FLUID WELL <br />benton1 to From <br />HYDROFRACTURED? [:]Yes )'No <br />ft. To ft. <br />Show exact location <br />_;___ __! __ <br />t t <br />t t <br />i <br />of well/boring in section gid with "X" Sketch map of well/boring location. <br />Showing property lines, <br />N jj ���. roads, buildings, and direction. <br />__ __ ___ __ ( <br />j <br />t <br />f <br />USE <br />X Domestic ❑ Monitoring ❑ Heating/Cooling <br />❑ Noncommunity PWS ❑ Environ. Bore Hole ❑ Industry/Commercial <br />❑ Community PWS ❑ Irrigation ❑ Remedial <br />E] Elevator E] Dewatering ❑ <br />w <br />f ~1 <br />E T <br />S k Mite ! <br />> !� <br />CASING MATERIAL Drive Shoe? ❑ Yes No <br />❑Steel ❑ Threaded ❑ elded <br />Plastic <br />HOLE DIAM. <br />Q C <br />8 in. To50 ft. <br />6k in. T110 ft. <br />CASING <br />Diameter Weight Specifications <br />[ <br />T In. To IM ft. lbs./ft. <br />in. To ft. lbs./(t. <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Nor -Son Inc. <br />in. To ft. lbs./ft. <br />in. To ft. <br />SCREEN <br />HOLE <br />From ft. TO ft. <br />Property owner's mailing address if differentOPEN <br />than well location address indicated above. <br />1700 E lake St #2 13 <br />TRayzata, M 55391 <br />Make $m <br />Type sta n ess steel Dia / <br />Slot/Gauze .15 Length Jk� ♦ 4 t <br />Set between —1j00 ft. and I ft. FITTINGS 2 - VII ISIMpli <br />STATIC WATER LEVEL 4S ft. gBelow ❑ Above land surface <br />Date measured Dry hole ❑ Yes eNo <br />WELL OWNER'S NAMEICOMPANY NAME <br />PUMPING LEVEL (below land surface) <br />as ft. after hrs. pumping g p m <br />Well/boring owner's mailing address if different than property owners address indicated above. <br />WELLHEAD COMPLETION <br />❑ Pitless/adapler manufacturer Model <br />❑ Casing protection ❑ 12 in. above grade <br />❑ At -grade , Well House ❑ Hand Pump <br />GROUT INFORMATION (specify bentonite, cement -sand, neat -cement, concrete, cuttings, or other) <br />Matedal bent note From 0 To 50 ft. 3 E]Yds. )gSags <br />Matedal CUt tinge From5 <br />To 100 ft. [-]Yds. ❑ Bags <br />Material From To ft. E] Yds. ❑ Bags <br />Driven casing seal From To _Bags One bag = 94 lbs. cement <br />or 50 lbs. bentonite <br />r� GEOLOGICAL MATERIALS <br />COLOR <br />HARDNESS OF <br />MATERIAL <br />FROM <br />TO <br />clay <br />brawn <br />medium <br />0 <br />27 <br />NEAREST KNOWN SOURCE OF CONTAMINATION <br />,., _ _.. <br />Well is � feet / `� .direction from type <br />Well disinfected upon completion? XYes [:]No <br />clay <br />gray <br />medium <br />27 <br />40 <br />PUMP <br />F-1Notinstalled Dale installed � � - � tgravel./sand <br />ix <br />meditEn <br />40 <br />90 <br />Manufacturer's name <br />Model Number 2 HP ' � Volts a3o <br />sand <br />brown <br />soft <br />90 <br />110 <br />Length of drop pipe t/ 3 ft. Capacity g.p.m <br />Type: Submersible ❑ L.S. Turbine ❑ Reciprocating ❑ Jet ❑ <br />ABA DONED WELLS <br />Does property have any not In use and not sealed well(s)? [-]Yes o <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes Y No TN# <br />WELL CONTRACTOR CERTIFICATION <br />Use a second <br />sheet, if needed. <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 />tst Co,,REMARKS, <br />Don Stodola Well Trilling Ca Inc. 1691 <br />ELEVATION, SOURCE OF DATA, etc. <br />Licensee Business Name Lic. or Reg. No. <br />9-5-19 <br />0,066ine ati ign ure Certified Rep. No. Date <br />Rob Stodola <br />LOCAL COPY <br />1839622 <br />Name of Driller <br />It) #b2fiu3 HE -01205-17 (Rev. 5/17) <br />