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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 C <br /> Minnesota Statutes,chapter 1031 <br /> Hennepin <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> rOono ry r?c V4 I/4 V., it. 9 i 1.i fJ 2 I,S <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> ❑Auger n Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> 3 VI5 ?^ , ' -r•e-t 9 ' r o r 5 s? DRILLING FLUID Wilt HYDROFRACTURED? ❑Yes ❑No <br /> Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. From ft.To ft. <br /> Showing property lines, <br /> N roads,buildings,and direction. USE ❑Domestic ❑Monitoring ❑Heating/Cooling <br /> 1 1 1 i t <br /> j 1 i : I I �%. ' y� ' ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> Li\.. j ❑Community PWS ❑Dewatering ❑Remedial <br /> -�- + F -I-- _... 1 ❑Elevator ❑ <br /> W E J {j CASING MATERIAL <br /> T Qw Drive Shoe? ❑Yes No HOLE DIAM. <br /> - -T r -` ❑Steel ❑Threaded ❑Welded <br /> /z Mile ❑Plastic ❑ <br /> 1 I I 1 <br /> '- -'- ' 1 CASING <br /> ' g ' ' Diameter Weight Specifications <br /> I 1 Mile I in.To ft. lbs./ft. in.To ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. ` ` in.To ft. <br /> i t. in.To ft. lbs./ft. in.To ft. <br /> r <br /> - e rid s3[ On e S yes - OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. SCREEN <br /> .J - <br /> t Make f T: 01"I From ft. To ft. <br /> 15250 Wayzata Blvd Type stainless Diam. '. <br /> i,Ja y z a t a MN 55391 Slot/Gauze . 15 Length 7 ' <br /> Set between 1 95 ft.andl 95 ft. FITTINGS <br /> STATIC WATER LEVEL //� 60 ft. LJ Below ❑Above land surface <br /> Date measured 9/1 4•1)2 3 Dry hole ❑Yes E]No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after 2 hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> 0 Pitless/adapter manufacturer monitor u.1 ftld'3iel <br /> ❑Casing protection X 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 Cut t i[l -'.rom 185 To 5 ft. ❑Yds. ❑Bags <br /> Material b e n.t o n i from 50 To 0 ft. ' ❑Yds. []Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Brown <br /> Well is feet _- direction from type <br /> Well disinfected upon completion? ❑Yes ❑No <br /> ,.,ia /Sa.nd Cray. S 25 1 ''', <br /> PUMP <br /> ❑Not installed Date installed 9/2 6 12 3 am /Grave 1 ' I 18 z ':T _ <br /> _ 5 .: r <br /> Manufacturer's name <br /> j 30 <br /> Model Number HP - ' Volts <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Type:[Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> ,,,,- <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 1j 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. <br /> on Stodola Well Dril1in Cc Inc 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> ." 55' /2 /2' <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY 8 694 21 Rob StodolaName of Driller <br /> ID#52603 HE-01205-18(Rev.3/19) <br />