07-30-2021 Well & Boring Construction Record

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IIAIAIAIFQnTG I muni IF Wrl I WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. WELL AND BORING CONSTRUCTION RECORD 857047 County Name ITenneoln Minnesota Statutes, chapter 1031 Township Name Township No. Range No. Section No. Fraction (sm. —. Ig.) WELUBORING DEPTH (completed) DATE WORK COMPLETED nrnnn � 117 23 6 SM SW' 150 7/30121 GPS LOCATION — decimal degrees (to four decimal places). DRILLING METHOD Latitude Longitude ❑ Cable Tool Driven ❑ Dual Rotary ❑ Auger Rotary ❑ Rotasonic ❑ Other House Number, Street Name, City, and ZIP Code of Well Location 705 Pine Hurst Ct, Orono 55364 DRILLING FLUID WELL n C �� i t e From HYDROFRACTURED? E] Yes No ft. To ft. Show exact location of well/boring in section grid with "X" Sketch map of well/boring location.�A howing property lines, N road.- ildings, and direction. USE ® Domestic ❑Monitoring ❑ Heating/Cooling ❑Noncommunity PWS ❑irrigation ❑Industry/Commercial ❑ Community PWS ❑Dewatering ❑Remedial i --- ---`- ---`- ' ❑ Elevator w E :\ CASING MATERIAL Drive Shoe? E] Yes No HOLE DIAM. ❑ Steel ❑ Threaded ❑ Welded '/ Mile ~ t ®Plastic ❑ CASING Diameeter 7 / Weight Specifications 4in1 ` . To 0 ft. lbs./ft. in. To ft. lbs./ft. --�--- -T-- -- �-- —t-- ' 1 s ��--� f 8 in. To 5 /oft. 5.5 in. TJ 5 0 ft. 1 Mile PROPERTY OWNER'S NAME/COMPANY NAME Swanson Hopes in. To ft. lbs./ft. in. To ft. SCREENYea _ OPEN HOLE� From ft. To ft. Property owner's mailing address if different than well location address indicated above. 1360 Hamel Road Make neon Type stainless Diam. 115 Medina, ! 55340 Slot/Gauze • Length 9 Set between 0 ft. and 150 ft. FITTINGS 3 Iflead STATIC WATER LEVELft. Below [:]Above land surface Date measured 7/30/21 Dry hole ❑ Yes X] No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL (below land surface) 135 ft. after 2 firs. pumping 40 V g.p.m. Welliboring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION Wrl Pitless/adapter manufacturer ildhi t o tog t a r Model Casing protection [ 12 in. above grade ❑ At -grade ❑ Well House ❑ Hand Pump GROUT INFORMATION (specify bentonite, cement -sand, neat -cement, concrete, cuttings, or other) Material CUt t in_98From 140 To 50 ft. ❑ Yds. ❑ Bags Material eT*nn to%m 50 To 0 ft. 3 —[]Yds. [Bags Material From To ft. [-]Yds. E] Bags One ba 94 lbs. cement Driven casing seal From To _ Bagsg - or 50 lbs. bentonite GEOLOGICAL MATERIALS COLOR HARDNESS OF MATERIAL FROM TO clay brown M 0 17 NEAREST KNOWN SOURCE OF CONTAMINATION /// p 10 Well is feet ! Y direction from �G type Well disinfected upon completion? [XYes ❑ No If Clay/ Sand Ura y 117 75 1 PUMP F-1Notinstalled Date installed 9/29/21 Manufacturer's name Shafer Sand/Gravel Mix S 75 93 Fine Sand raven S 9 3 11$ Model Number 126 HP 1 e 5 volts 2 30 Length of drop Pi e ft. Capacity 9�P�m Gravel Mix 4 118 133 Type: [submersible ❑ L.S. Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS Sand r n LJn S 1 9 J 1 5 r> 1 0 Does property have any not in use and not sealed well(s)? ❑ Yes o VARIANCE Was a variance granted from the MDH for this well? ❑ Yes No TN# WELL CONTRACTOR CERTIFICATION Use a second sheet, if needed. 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. REMARKS, ELEVATION, SOURCE OF DATA, etc. Don Stodola Well Drilling Co 1691 Licensee Business Name Lic. or Reg. No. f.. 558 7130/2 i epresentati a Signa re Certified Rep. No. Date Rob Stodola LOCAL COPY 857047 Name of Driller IIE-01205-18 (Rev.3/19)