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AAIAIAIF QnTA I IAIIniW IA/FI I <br />WELL OR BORING LOCATION <br />MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br />WELL AND BORING CONSTRUCTION RECORD 860839 <br />County Name <br />Hennepin <br />Minnesota Statutes, chapter 1031 <br />Township Name <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. —. Ig.) <br />WELLBORING DEPTH (completed) <br />DATE WORK COMPLETED <br />Orono <br />117 <br />23 <br />06 <br />NE NE SW <br />105 <br />12/7A/21 <br />GPS LOCATION — decimal degrees (to four decimal places). <br />DRILLING METHOD <br />Latitude Longitude <br />❑ Cable Tool 1 Driven ❑ Dual Rotary <br />❑ Auger [Rotary ❑ Rotasonic <br />E] Other <br />House Number, Street Name, City, and ZIP Code of Well Location` <br />O <br />�b <br />415 North Arm Drive O ro W <br />DRILLING FLUID WELL <br />BentoniteFrom <br />HYDROFRACTURED? E]Yes No <br />ft. To ft. <br />Show exact location <br />» <br />of well/boring in section grid with "X" Sketch map of well/boring location. <br />Showing property lines, <br />N roads, buildings, and direction. <br />USE ® Domestic ❑ Monitoring ❑ Heating/Cooling <br />L__ ___�__ <br />❑ Noncommunity PWS ❑ Irrigation E]Industry/Commercial <br />❑ Community PWS ❑ Dewatering ❑ Remedial <br />--i--- -- ,'-- <br />-- ------ -- <br />❑Elevator El <br />w <br />E T <br />CASING MATERIAL Drive Shoe? ❑ Yes N No <br />HOLE DIAM. <br />I <br />I I <br />❑ Steel ❑ Threaded ❑ Welded <br />�—t Mile <br />kMile <br />s <br />[� Plastic ❑ <br />in. T.5 0 ft. <br />CASING <br />Diameter Weight Specifications <br />4 in. To 100 ft. lbs./ft. <br />in. To ft. lbs./ft. <br />C <br />• J in. Tot 10ft. <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Morton Homes <br />in. To ft. lbs./ft. <br />in. To ft. <br />SCREEN-�e$_ <br />OPEN HOLE <br />From ft. To ft. <br />Property ovfners mailing address if different than well location address indicated above. <br />I <br />1845 -45th Ave No Ste D <br />Flyviouth, MN 55446 <br />Make Johnson <br />Type $ta nes$ Dia.. Z <br />Slot/Gauze 0 10 Length <br />Set between ft. and 108 ft. FITTINGS 3T ea <br />STATIC WATER LEVEL ft. [T -Below, E] Above land surface <br />Date measured 12/28/21 Dry hole ❑ Yes [*No <br />WELL OWNER'S NAME/COMPANY NAME <br />PUMPING LEVEL (below land surface) <br />r� <br />95 ft. after 2 hrs. pumping 40 — <br />g-p.m-Well/boring owner's mailing address if different than property owner's address indicated above. <br />WELLHEAD COMPLETION - <br />Pitless/adapter manufacturer - CAL- 4a t.0 , 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 />Material Cutting $From 100, 50 ft. ❑ Yds. ❑ Bags <br />Material bent on tK%m— ff. ❑ Yds. [Bags <br />Material From To ft. ❑ Yds. ❑ 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 />NEAREST KNOWN SOURCE OF CONTAMINATION <br />top soil/clay <br />t. <br />U 1 k/ <br />Y r m <br />0 <br />7 <br />Well is ' Q feet G direction from type <br />Well disinfected upon completion? Pq Yes ❑ No <br />clay <br />brown <br />m <br />7 <br />16 <br />PUMP <br />[j Not installed Date installed <br />Manufacturer's name <br />Model Number HP Volts <br />"u <br />Length of drop pipe �` ft. Capacity----:)09-p.m <br />C l al <br />Gra <br />16 <br />L <br />6 2 <br />Sand/clay <br />(;ray <br />S <br />62 <br />81 <br />Sand <br />Brown <br />S <br />til <br />110 <br />Type: V] 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? [j Yes jt] No TN# <br />WELL CONTRACTOR CERTIFICATION <br />Use a second <br />sheet, if needed. <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 />REMARKS, ELEVATION, SOURCE OF DATA, etc. <br />Don Stodola Well Drilling; Co 1691 <br />Licensee Business Name Lic. or Reg. No. <br />~' = 558 12/28/21 <br />(Mniffdd ftepresirntaflVe Si nature Certified Rep. No. Date <br />Rob Stodola <br />LOCAL COPY <br />Name <br />e of Driller <br />ID#52603 HE01205-18(Rev.3/19) � I <br />