12-07-2020 Well and Boring Construction Record

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MINNFSnTA UNlnl /F WFLI WILL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. WELL AND BORING CONSTRUCTION RECORD 848566 County Name Minnesota Statutes, chapter 1031 Towns ip a Township No. Range No. Section No. Fraction (sm. —. Ig.) WELUBORING DEPTH (completed)DATE WORK COMPLETED Or 117 23 07 SST NR PSE % 219 ft. 12-7-2n GPS LOCATION — decimal degrees (to four decimal places). Latitude Longitude DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dual Rotary ❑ Auger f Rotary ❑ Rotasonic ❑ Other T House Number, Street Name, City, and ZIP Code of Well Location `, 900 Forest Arm Trane, Orono 55364 DRILLING FLUID WELL beento -, a t-2 From HYDROFRACTURED? ❑ Yes No ft. To ft. Show exact location of welllboring in section grid with "X" Sketch map of well/boring location. Showing property lines, N roads, buildings, and direction. USE Domestic ❑ Monitoring ❑ Heating/cooling ---------- ❑ Noncommunity PWS ❑ Irrigation ❑ Industry/Commercial ❑ Community PWS ❑ Dewatering ❑ Remedial t ❑ Elevator CASING MATERIAL Drive Shoe? E] Yes XNo ❑ Steel E]Threaded E]Welded HOLE DIAM. w E T ,- - -- - -- -- I 'k mileC' '0 S Plastic ❑ CASING Diameter Weight Specifications —i Mile r �7 g� Cr,� — in. To 210 It. lbs./ft. in.To ft. lbs./ft.in.To in. To%ft. ft. PROPERTY OWNER'S NAME/COMPANY NAME C R J Cions t NC t ion in. To ft. lbs./ft. in. To ft. SCREEN OPEN HOLE From ft. To ft. Property owner's mailing address if different than well localio 7ddroess indicated above. 3500 QiLCni7rJUL�' urstFi>r Ste I 35 Vic bu 655447 �mo # Make Johnson Type StainjeaS steel Diam. 2" Slot/Gauze r. Length Set between. and ft. FITTINGS STATIC WATEL 65 ft. a ow ove rand surface A Date measured 12-7-20 Dry hole ❑ Yes KNO WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL (below land surface) 205 ft. after hrs. pumping SAF q.p.m. WelVboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Pitless/adapter manufacturer Whi t eym t rY r Model ❑ Casing protection Di12 in. above grade ❑ At -grade ❑ Well House ❑ Hand Pump GROUT INFORMATION (specify bentonite, cement -sand, neat -cement, concrete, cuttings, or other) bentoniteFrom Toft. 0 50 3 ❑ Material —cry �f7� Yds. ags Material CUt�From „l To—2W ft. ❑ Yds. ❑ Bags Material From To ft. ❑ Yds. ❑ Bags One ba 94 lbs. cement Driven casing seal From To _Bags9- or 50 lbs. bentonite GEOLOGICAL MATERIALS COLOR HARDNESS OF MATERIAL FROM TO C Lay eley clayrOC�:3Cci�i `hrocni U G Tied icArl �C1111fTt n 25 90 25 108WeII NEAREST KNOWN SOURCE OF CONTAMINATION Well is 85 feet N direction fromd ty sem—eC type disinfected upon completion? ['Yes ❑ No air tested PUMP 'ire ^x112 elay anO/E,ravel heoTar mix Oft -12— kle!illm 116 194 210 1;4 210 220 F-1 Not installed Date installed 3/9/21. Manufacturer's name Shafer Model Number HIP volts 300 Length of drop pipe 84 ft. Capacity 9 -p.m Type: [X Submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes YN. VARIANCE Was a variance granted from the MDH for this well? ❑ Yes Xo 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. ,7 Don Stodola W$11 Drilling; CO., Inc. 1691 Use a second sheet, if needed. REMARKS, ELEVATION, SOURCE OF DATA, etc. Licensee Business Name Lic: or Reg. No. 12-21-20 66rfiff6d Representative Si nature Certified Rep. No. Date LOCAL COPY 18485661 Name of Driller ID #52603 ne-uizuo-ia (nev.ai i a.