07-09-2021 Well & Boring Construction Record

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',nn, rarxv��mrair�rr�t WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. WELL AND BORING CONSTRUCTION RECORD County Name Hennepin Minnesota Statutes, chapter 10.91 857044 Township Name Township No. Range No. Section No. Fraction (sm. — Ig.) WELL/BORING DEPTH (completed) DATE WORK COMPLETED Orono 118 123 27 Sid Sid,, Stf ,,, 267 "" 7/9/21 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 736 Dickey bake Rd Lake MN 55356 DRILLING FLUID WELL Bentonite From HYDROERACTURED? ❑ Yes No ft. To ft. Show exact location ----------- __ of well/boring in section grid with "X" Sketch map of well/boring location. Showing property lines, N roads, buildings, a d- jection. ___L__ ___L__ S USE K Domestic ❑ Monitoring ❑ Heating/Cooling ❑ Noncommunity PWS ❑ Irrigation ❑ Industry/Commercial '--- -- W �j ---F------ I— �T E ❑ Community PWS ❑ Dewatering ❑ Remedial ❑ Elevator ❑ CASING MATERIAL Drive Shoe? ❑ Yes ® No HOLE DIAM. , r-- �1Mile� 'h Mile T ------ ---- 1 s Steel E] Threaded E] Welded Plastic El® 1.3 in. To 50 ft. CASING jDiameter Weight Specifications "� in. To 257 ft. lbs./ft. in. To ft. lbs./ft. 6.5 in. To 267ft. PROPERTY OWNER'S NAME/COMPANY NAME James Joseph in. To ft. lbs./ft. in. To ft. SCREEN YIN OPEN HOLE From ft. To ft. Property owner's mailing. address if different than well location address indicated above. same - L,�,,, Make Johnson N Type stainless Diam. 2 Slot/Gauze �1f15 H � Length 81 lead �,.,7 Set between 257 ft. and 2 7 ft. FITTINGS 3 lead STATIC WATER LEVEL 115 ft. X Below ❑ Above land surface Date measured 7/9/21 Dry hole ❑ Yes EXNo WELL OWNER'S NAMEICOMPANY NAME PUMPING LEVEL (below land surface) 250 ft. after 2 hrs. pumping 75 o.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION a ® Pitless/adapter manufacturer IfUteWater Model ❑ Casing protection ❑ 12 in. above grade ❑ Ai -grade ❑ Well House ❑ Hand Pump GROUT INFORMATION (specify bentonite, cement -sand, neat -cement, concrete, cuttings, or other) Material cuttings m 257 To 50 ft. ❑ Yds. ❑ Bags Material nto teFrom— 30—To_7G_ft. —3 E:] Yds. [Bags Material From To ft. [:]Yds. [:]Bags Driven casing seal From To _Bags One bag = 94 lbs. cement or 50 lbs. bentonite GEOLOGICAL MATERIALS COLOR HARDNESS OF MATERIAL FROM TO NEAREST KNOWN SOURCE OF CONTAMINATION Clay brwn M 0 17 Well isfeet septic direction from SE type Clay/Sand Gray M 17 257 Well disinfected upon completion? ® Yes ❑ No PUMP ❑ Not installed Date installed 7/13/21 Sand mix ?S 57 267 Manufacturers name Shafer 1 230 Model Number HP Volts Length of drop pipe 147 ft. Capacity 10 g.p.m Type:® Submersible ❑ L.S.Turbine [_]Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed welf(s)? ❑ Yes ?;No VARIANCE Was a variance granted from the MDH for this well? ❑ Yes Pq 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, 1691 Licensee Business Name Lic. or Reg. No. ' Ceftlli d ?es native Signat e Certified Rep. No. Date LOCAL COPY 1857044 Name of Driller ID #52603 HE-012ub-le (Hev.3/19)