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AA1A1A19:QlITd IIMIn11F IAIFI I <br />Vj ELL OR BORING LOCATION <br />MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br />WELL AND BORING CONSTRUCTION RECORD <br />Minnesota Statutes ch1.apter 1031 839621 <br />ounty Name <br />ntkpin <br />Township Name <br />Township No. <br />flange No. <br />Section No. <br />Fraction (sm. —. Ig.) <br />WELUBORING DEPTH (completed) <br />DATE WORK COMPLETED <br />Orono <br />117 <br />23 <br />08 <br />'-M. = SE v <br />192 <br />4-0-19 <br />GPS LOCATION —decimal degrees (to four decimal places). <br />Latitude Longitude <br />DRILLING METHOD <br />❑ Cable Tool Llrnriven ❑Dual Rotary <br />❑ Auger Rotary ❑ Rotasonic <br />❑ Othpr <br />House Number, Street Name, City, and ZIP Code of Well Location <br />3260 North Shore Dr, Orono 55391 <br />DRILLING FLUID WELL HYDROFRACTURED? ❑ Yes No <br />bentonite <br />From ft. To ft. <br />USE Domestic ❑ Monitoring ❑Heating/Cooling <br />Show exact location <br />of well/boring in section grid with "X:' Sketch map of well/boring location. <br />Sho. i r ert Mines, <br />N[gads, biyl a 2lcdch�IT' <br />__ <br />-_ <br />------ ------- <br />❑ Noncommunity PWS ❑ Environ. Bore Hole ❑ Industry/Commercial <br />4 <br />❑ Community PWS ❑ Irrigation ❑ Remedial <br />--- -- --- <br />-- -- --- -- <br />❑ Elevator ❑ Dewatering 11W <br />I <br />CASING MATERIAL Drive Shoe? ❑Yes No <br />HOLE DIAM. <br />--�--- --�--- <br />-- ------t-- <br />Steel ❑Threaded Vlelded <br />1 <br />1 <br />Plastic ❑ <br />T <br />. 1 Mile <br />> <br />s <br />�� .} � <br />in. To__ %ft. <br />CASING <br />Diameter Weight Specifications <br />in. To 83 ft. lbs./ft. <br />in. To ft. lbs./ft. <br />in. ToMft. <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />R A Antler ` Pro rt i.es f�V <br />LLC J <br />n. To ft. lbs./ft. <br />in. To ft. <br />SCREEN <br />Make <br />OPEN HOLE <br />From ft. To ft. <br />Property owner's mailing a res if different than well location address indicated above. <br />3�a�0�5�}Cayat� ��3gld <br />J "p <br />SType lot/Gauze a n esB steel Diam. <br />0 Length 4' + 4' <br />( . ' <br />Set between _— ft. and 1 q2 ft. FITTINGS 2!x33 leader -- <br />eaderSTATIC <br />STATIC WATER LEVEL 34 .)<Below ❑ Above land surface <br />Date measured 40*8-19 Dry hole ❑ Yes No <br />WELL OWNER'S NAME/COMPANY NAME <br />PUMPING LEVEL (below land surface) <br />185 ft. after 2 hra. pumping o.p.m. <br />Welliboring owner's mailing address if different than property owner's address indicated above. <br />WELLHEAD COMPLETION <br />Pitless/adapter manufacturer W Model <br />Casing protection 12 in. above grade <br />❑ At -grade ❑ Well House [-]Hand Pump 7� <br />GROUT INFORMATION (specify bentonite, cement -sand, neat -cement, concrete, cuttings, or other) <br />Material1�n�njjte�From... *__ To__50_ ft. _ 3 ❑ Yds. XBags <br />Material <br />f�From� To -183— ft. L]Yds. ❑ Bags <br />Material , From To ft. ❑ Yds. ❑ Bags <br />Driven casing seal From To _BagsOne ba - 9 94 lbs. cement <br />.r501bs. bentonite <br />GEOLOGICAL MATERIALS <br />COLOR <br />HARDNESS OF <br />MATERIAL <br />FROM <br />TO <br />Peat <br />black <br />soft <br />0 <br />7elay/send <br />NEAREST KNOWN SOURCE OF CONTAMINATION <br />r - <br />Well is feet direction from �J 4—) -3tt.-iyp <br />Clay <br />sandlelay <br />clay/sand <br />gray <br />gray <br />gray <br />gray <br />90ft <br />medium. <br />soft <br />Medium <br />25 <br />65 <br />90 <br />25 <br />65 <br />90 <br />133 <br />Well disinfected upon completion? Yes ❑ No <br />PUMP <br />❑Not installed Date Installed <br />gravel/clay <br />Uray <br />11}edtAI <br />166 <br />174 <br />Manufacturer's name <br />Model Number HP Volts <br />elay <br />sandstone/shale <br />gray <br />white <br />meditri, <br />soft <br />174 <br />fr33 <br />183 <br />192 <br />Length of drop pipe ft. Capacity , 9 -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 4N. <br />VARIANCE <br />Was a variance granted from the MDH for this well? [-]Yes 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 second <br />sheet, if needed. <br />REMARKS, ELEVATION, SOURCE OF DATA, etc. <br />Don Stodola Well DrilliTig Co. Inc. 1691 <br />Licensee Business Name Lic. or Reg. No. <br />00, <br />9-26-I <br />CgVNle&ffepriKemattve signature Certified Rep. No. Date <br />Stodola <br />LOCAL COPY <br />6 3 9 6 21Rob <br />Name of Driller <br />IU #526U3 Ht-uleua-1I lHev. on 1) <br />