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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND.BORING CONSTRUCTION RECORD 8 4 H 5 7 <br /> Rennepin <br /> Minnesota Statutes,chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction(sm.--+lg.) WELLBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 '1 08 NW NW NNA _ 7„ ". 9/30/22 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool R Driven ❑Dual Rotary <br /> ❑Auger Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> 1040 Loa Linda, Orono 5 364 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes ]No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. Be tit tin i t e From ft.To ft. <br /> Showing property lines, <br /> roads,buildings,and direction. USE <br /> NI Domestic ❑Monitoring ❑Heating/Cooling <br /> ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> IElCommunity PWS ❑Dewatering ❑Remedial <br /> }' ❑Elevator Liw ET ,L CASING MATERIAL Drive Shoe? ❑Yes [ No HOLE DIAM. <br /> t V ❑Steel ❑Threaded ❑Welded <br /> 'k Mile °,, ,../ <br /> � [Plastic ❑ <br /> -,, ' CASING <br /> ' g ''' y Diameter Weight Specifications <br /> 1 1 Mile in.To ft. lbs./ft. in.To, ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To; ft. lbs./ft. �' in.To . <br /> Fox <br /> in.To ft. lbs./ft. in.To ft. <br /> A_ <br /> SCREE .J' r OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. N s c v <br /> Make "r From ft. To ft. <br /> Wayzata <br /> Blvd <br /> Type s t as I n e s s Diam. `f. " t� <br /> Suite 15 Slot/Gauze •12 Length 8' t <br /> "Innetonka 55105 Set between 160 ft.and 65 ft�. FITTINGS 3' i' d <br /> STATIC WATER LEVEL <br /> /y / it 5 ft. ]Below ❑Above land surface <br /> Date measured 9/ 3 0 J 22 Dry hole ❑Yes l]No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after hrs.pumping g.p.m. <br /> 2 <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> xi Pitless/adapter manufacturer Monitor <br /> 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 /> Materialtt bentonrom 1?.-' to ft. ❑Yds. ❑Bags <br /> Material From To ft. - ❑Yds. J Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag94 lbs.cement <br /> Driven casing seal From To Bags - <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION air e 5 t e r.1 <br /> Clay 7trown, 1k4 0 2 q Well is feet `' direction from city sewer <br /> p <br /> Well disinfected upon completion? ]Yes ❑No <br /> Slay/Sand. Gray 1 29 102 PUMP <br /> ❑Not installed Date installed <br /> Sand. T Gravel Mix 9 102 112 Manufacturer's name Shafer <br /> Model Number HP Volta <br /> Fine Sand Gray S 117 156Length pipe 4 ft. Capacity m. <br /> 9 P PiP P y g•p <br /> Type:y]Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> Sand Brown S 156 1 {0 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? ❑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 sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. n Stools Well Drilling Co. ,Inc. 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> 55 1-cliVV27. <br /> l `d Aepresentati re ignature. Certified Rep.No. Date <br /> LOCAL COPY 848573 Name of Driller <br /> iD#52603 HE-01205-18(Rev.3/19) _ <br />