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MINNESOTA UNIQUE WELL <br />WELL OR BORING LOCATION <br />MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br />WELL AND BORING CONSTRUCTION RECORD 857048 <br />County Name <br />Iu-nnepin <br />Minnesota Statutes, chapter 1031 <br />Township Name <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. Ig.) <br />WELUBORING DEPTH (completed) <br />DATE WORK COMPLETED <br />Orono <br />117 <br />23 <br />06 <br />SE SW% SW %125 <br />7/28/21 <br />GPS LOCATION — decimal degrees (to four decimal places). <br />Latitude Longitude <br />DRILLING METHOD <br />❑ Cable Tool ❑ Driven ❑ Dual Rotary <br />❑ Auger Rotary ❑ Rotasonic <br />❑ Other <br />House Number, Street Name, City, and ZIP Code of Well Location <br />710 Lakeview Parkway Orono W 55364 <br />DRILLING FLUID WELL <br />Bentonite From <br />HYDROFRACTURED? ❑ Yes ® No <br />ft. To ft. <br />Show exact location <br />of well/boring in section grid with "X" Sketch map of welllboring location. <br />Showing property lines, <br />N roads, buildings, and direction. <br />USE ® Domestic ❑ Monitoring ❑ Heating/Cooling <br />❑Noncommunity PWS ❑Irrigation ❑ Industry/Commercial <br />❑ Community PWS ❑Dewatering ❑ Remedial <br />'--- <br />W <br />--- ------ <br />E i` <br />Elevator <br />CASING MATERIAL ve Shoe? �J No <br />i ❑ <br />Dr Yes <br />HOLE DIAM. <br />'""" <br />"" "" ""'"" T `r <br />❑ Steel ❑ Threaded ❑ Welded <br />--�--- --�--- <br />1 Mile <br />'h Mile ``v <br />-- �-- --%-- I / x W f_' 11 <br />s 1 <br />Plastic ❑ <br />p <br />$ in. To 50 n. <br />CASING <br />Diameter Weight Specifications <br />4 in. To 115 ft. lbs./ft. t. <br />in. To ft. lbs./ft. <br />in. To12-5 ft. <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />tbrton ftnes <br />in. To ft. lbs./ft. <br />in. To ft. <br />SCREEN ye"g <br />OPEN HOLE <br />From ft. To ft. <br />Property owners mailing address if different than well location address indicated above. <br />g <br />18215 45th Ave N <br />Plymwth, M 55446 <br />Make .�� i <br />Type s & n ea Diam. <br />Slot/Gauze Length 13 <br />lead <br />Set between n. and ft. FITTINGS 31 leadt <br />STATIC WATER LEVEL 44 ft. [N Below LJ -Above land surface <br />Date measured 7//28/21 Dry hole ❑ Yes X1 No <br />WELL OWNER'S NAME/COMPANY NAME <br />PUMPING LEVEL (below land surface) <br />110 ft. after 2 hrs. pumping 40 q.p.m. <br />Well/boring owner's mailing address if different than property owner's address indicated above. <br />WELLHEAD COMPLETION Ll <br />Pitless/adapter manufacturer .ftteWater 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 />Materials�CuttinSIS From 115 To 50 ft. E]Yds. E]Bags <br />Materiatbentoni.te From 50 To 0 ft. 3 ❑ Yds. J ] Bags <br />Material From To ft. ❑ Yds. L]Bags <br />Driven casing seal From To _ Bags One bag = 94 lbs. cement <br />or 50 lbs. bentonite <br />GEOLOGICAL MATERIALS <br />COLOR <br />HARDNESS OF <br />MATERIAL <br />FROM <br />TO <br />Clay <br />Brown <br />M <br />0 <br />16 <br />NEAREST KNOWN SOURCE OF CONTAMINATION <br />Well is ) � _/ \ feet / CO direction from Se h C' type <br />Well disinfected upon completion? CRYes ❑ No <br />Clay <br />Gray <br />M <br />L6 <br />77 <br />Ipump <br />❑ Not installed Dale installed 8/11/21 <br />,9and <br />Brown <br />S <br />77 <br />e <br />105 <br />Manufacturer's name Shafer <br />Model Number HP 1.5 Volts 230 <br />Length of drop pipe 63 n. Capacity 9 -p.m <br />& <br />Sand Gsa <br />Mix <br />M <br />105 <br />125 <br />Type: [X Submersible ❑ L.S. Turbine [-]Reciprocating ❑ Jet ❑ <br />ABANDONED WELLS <br />Does property have any not in use and not sealed well(s)? ❑ Yes ® No <br />VARIANCE <br />Was a variance granted from the MDH for this well? [:]Yes XJ 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 seco <br />nd sheet, it needed. <br />REMARKS, ELEVATION, SOURCE OF DATA, etc. <br />Wall <br />Licensee Business Name Lic. or Reg. No. <br />� 558 7/28/21 <br />Cli a 11e seFl ative tigrratuW Certified Rep. No. Date <br />R°b stoaoi8 <br />LOCAL COPY �8570481 <br />Name of Driller <br />ID#52603 Nt .zuo- ie tnevanal <br />