03-30-2021 Well & Boring Construction Record

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• ii I 1MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name . WELL AND BORING CONSTRUCTION RECORD n Hennepin - Mi snesota Statutes,chap 8 �]a93I 5 1 0 2`Y' 1 Township Name- 'Township No. Range N . ,Section No. t Fraction(sm. Ig.) WELUBORING D PTH(completed) DATE WORK COMPLETED Orono117 23 ., 06 - v. SE W 149 ft. 3/30121 DRILLING METHOD y. GPS LOCATION—decimal degrees(to foufdecimal places). Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary • ❑Auger X Rotary ❑Rotasonic HH�oLI Parkway . et Name,City,and ZIP Code of WelfLocati ❑Other 130 ar y. Grono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes A No Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. Eentord.te From ft.To ft. Showing property lines, • N ' roads,buildings,and direction. USE Xi Domestic ❑Monitoring ❑Heating/Cooling J _- __L__-_____,• \L"."'""*"...a,..:"Ij ❑Noncommunity PWS - ❑Irrigation IDIndustry/Commercial 1 wma ❑Community PWS ❑Dewatering ❑Remedial 1 ❑Elevator El'W - ECASING MATERIAL Drive Shoe? ❑Yes X No HOLE DIAM. _ --- 'h Mile V Plastic 111 -1 + Steel ❑Threaded Welded A• CASING S ;7'1: Diameter Weight Specifications I 1 Mile Iin.To 140 _ft. lbs-/ft. t in.To 5.0_ft. PROPERTP QWNER'S NAME/COMPANYlNAME i in. o ft. lbs-/ft. 6.5 in.To 150ft. Swans in.To ft.. lbs./ft. in.To ft. r SCREEN Yea OPEN HOLE Property owner's mailing address if different than well location address indicated above. L 1360 Hate' Roads in 55340 Make Mange From, ft. To ft. Medina Type Dial 2K SIoVGauze•15 Lengt AI tri • Set between .40 ft.and149 ft. FITTING3f lead STATIC WATER LEVEL 45 ft.XJ]Below ❑Above land surface '0 -1 ,,,,J.. .--, Date measured 3/30/21 Dry hole ❑Yes X No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) i„' z,r. 135 ft.after2 hrs.pumping 40 q.p.m. Well boring owner's mailing address if different than property owners address indicated above. WELLHEAD COMPLETION# L Pitless/adapter manufacturer del ❑Casing protection X 12 in.above grade 4i; ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION�{,� (specify bentonite,e,cement-sand,neat-cement,concrete,cuttings,or other) Material W3ttingQ From 140 To 50 ft. ❑Yds. 0 Bags 4. Material ROnteln'f tpFrom so To 0 ft. 3 ❑Yds. ]Bags Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO MATERIAL Driven casing seal From To Bags One bag=94 lbs.cement or 50 lbs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION Clay Brown N 0 16 Well is ! / feet Aldirection from Se 't1 type Well disinfected upon completion? IC Yes ❑No Clay Gray M 16 Sp PUMP ❑Not installed Date installed �om- 1 1(1 '� Sand/Gravel Bream /Y\tS 80 150 Manufacturer's name � ( 11 Y { Model Number HP r/S Volts .30 Length of drop pipe g4 I ft. Capacity g.p.m Type. Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes rg No VARIANCE Was a variance granted from the MDH for this well? ❑Yes ANo TN# WELL CONTRACTOR CERTIFICATION 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. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Don Stodola Well Drilling 1691 Licensee Business Name Lic.or Reg.No. 4119 f/' I✓ • -epresentati r:Si.na re Certified Rep.No. Date r LOCAL COPY 857024 `��) �j{-.'u L Name of Driller ID#52603 HE-01205-18(Rev.3/19)