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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BORINGTA WELLNIQUE NO. County`Name WELL AND BORING RECORD 792018 : Minnesota Statutes,Chapter 1031 Hennepin Township Name Township No. Range No. Section No.} Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 07 NW SR SE,/ 223 H. 9-12-13 GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds Longitude degrees minutes seconds ❑Cable Tool ❑Driven ❑Auger Rotary House Number,Street Name,City,and ZIP Code of Well Location Fire Number ❑Other yy V.;.a ,'.- , d,T4-1 .': 4,4 r i: .4'j'. 55364 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ,cccc,5''''o Show exact location of well/boring in section gri. Sketch map of well/boring location. bentonite From It.To ft. Showing property lines, N roads,buildings,and direction. USE Domestic ❑Monitoring ❑Heating/Cooling __._ I. � ❑Noncommunity PWS ❑Environ.Bore Hole ❑Remedial Industry/Commercial ❑Community PWS ❑Irrigation ❑Remedial F t ❑Elevator ❑Dewatering ❑ w ;` E ` CASING MATERIAL Drive Shoe? ❑Yes �'fdo HOLE DIAM. ---1--- ---F------ �h Mlle ❑Steel ❑Threaded ❑Welded lastic ❑ -Y I 1 CASING S Diameter Weight Specifications Q 1 Miie 4 in.To 215 ft. lbs./ft. 8 in.To 50ft. -273 PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.Tott. J Scot ty; Builders in.To ft. lbs./ft. in.To ft. � OPEN HOLE Property owner's maili g address if different than well location address indicated above. SCREEN Johnson 7935 Storamtreek Dr Make •�. From � tt. To ft. Type stainless steel Diam. G t WI 55317 Slot/Gauze .010 Length 4' + 4. Set between 415_ft.and_4123 ft. FITTINGS g 5 STATIC WATER LEVEL Measured from !f. 50 tttelow❑Above land surface Date measured 9-12-13 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 180 ft.after 4 _hrs.pumping 20 g.p.m. )ell/boring owner's mailing address if different than property owner's address indicated above. WE LHEAD COMPLETION y,ltd %itless/adapter manufacturer Rhi Model ❑Casing protection ,..1<12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUTINGINFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material bentonite From 0 To A�SOft. 3 ❑Yds. Bags Material natural ft(1r1...__SQ21To ltt. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags NEAREST KNOWN SOURCE OF CONTAMINATION fill/sand It brown soft 0 2 625 feet LAdirection Well disinfected upon completion? ,lYes ❑No - � ...L.I. clay brown soft 2 28 PUMP 10-1-13 clay pip ❑Not installed Date installed 1.:.L� gray l Manufacturer's name e� �ravel�sand varied medit�/soft 44 57 Model Number ®� HP leg_Volts_ l Length of drop pipe 84 tt. Capacity g.p.m. silt/sand gray soft 57 156 Typeubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS clay gray soft 156 187 Does property have any not in use and not sealed well(s)? ❑Yes�'No VARIANCE clay/send grey soft 1877 q 211 Was a variance granted from the MDH for this well? ❑Yes jgNo TNIt WELL CONTRACTOR CERTIFICATION {{,, �� q� This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. sand/gravelse a secon CJa ded. medium 211 223 The information contained in this report is true to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodola WellDrilling Co,. Inc. 1691 Note: Adrees was changed after permits wer@Licensee Business Name Lic.or Reg.No. tt• change 4199 North Shore Dr, Orono to S' / � f1-18-13 1565 Fairview Cottage Lane, Orono Re resentative = -t re Certified Rep.No. Date Ryan LOCAL COPY 792018 Name of Driller gaard IC 140-0020 HE-01255-13 IRev.11/10)