03-18-2022 Well & Boring Construction Record

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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTAAND BORING NO.WELL County Name - WELL AND BORING CONSTRUCTION RECORD 8 6 0 8 3 4 Hennepin Minnesota Statutes,chapter 1031 Township Name Township No. Range No. Section No. Fraction(sm. lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 07 NE t NE NE ft* 140 „. 3/18/22 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool IL Driven ❑Dual Rotary ❑Auger Rotary ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑Other 940.IYQrt i[! Arm Drifts, Orono DRILLING FLUID WELL HY ACTURED? ❑Yes X No Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. Bent oni t e From , ft.To ft. Showing property lines, roads,buildings,and direction. USE N /'. ' X Domestic ❑Monitoring ❑Heating/Cooling _____—________________ f ""`"" ) N ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial , t, ❑Community PWS ❑Dewatering ❑Remedial 2 r ❑Elevator ❑ w E ,,,; . „ i CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. -4- -r I �+ '' _ _ ❑Steel ElThreaded ❑Welded • 'h Mile.* - ID Plastic ❑ - 1 -Z CASING T s `. Diameter Weight Specifications 4�y ( Mile ' 4 in.To 130ft. lbs./ft. 6 8 in:To J 0 ft. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. + n.To ft. Ze hnd e r Homes Inc in.To,, ft. lbs./ft. in.To ft. SCREEN OPEN HOLE Property owner's mailing 10thaddresss if different than well location address indicated above. L . 10300:: . Ave No Make Johnson From r+g� ft. To ft. Plymouth, MN 55441 Type stainless Diam2W Slot/Gauze 5 Length 8 Set between". ft.and 1 0 ft. FITTINGS 3' lead STATIC WATER LEVELt ry 71 ft. Below ❑Above land surface Date measured 3!1 8!t 22 Dry hole ❑Yes Lilo WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 125 ft.after 2 hrs.pumping• 40 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION W IA` j —.t,�., /��y*'�,Hess/adapter manufacturer t'J Model E Casing protection above grade .At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material Cut t ingsrom 130 To 50 ft. ❑Yds. ❑Bags Material bentonite 50 To 0 ft. 3 ❑Yds. ".Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR 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 M. 0 18 ► tY�� C±'�'� � Well is feet ��//// f direction from i. c1ay Gray 18Well disinfected upon completion? Ayes ❑No air --4 en PUMP i Sandy Clay Brown M 32 40 X Not installed Date installed �t'1 {, i 3 b Manufacturer's name\(k,Ire V'" Clay Gray M 40 73 Model Number HP 1 ;(Z. Volts Length of drop pipe 105 ft. Capacity g.p.m. Pine Sand. Brown S 73 118 Type:[Submersible ❑L.S.Turbine ❑Reciprocating El Jet ❑ ABANDONED WELLS Water Sand Brown S 118 140 Does property have any not in use and not sealed well(s)? ❑Yes ae No VARIANCE Was a variance granted from the MDH for this well? ❑Yes gNo TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. 0,,. KW c'.l aDi Don Stodola Well Drilling Co 1691 LY\,c1�e" _ t CY \- Licensee Business Name Lic.or Reg.No. -S OL_VJC Y ::k --eC, AY k 11--e L i t } 558 3/18/22 \Y\ \) \ o •ed epr efitatiyyef ture Certified Rep.No. Date Q 4 Jv r I ._ t, ( LOCAL COPY 86083�. Name of Driller ID#52603 HE-01205-18(Rev.3/19)