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MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD 8 7 8 5 3 0 Kennep6i Minnesota Statutes,chapter 1031 Township Name Township No. Range No. Section No. Fraction(sm.—e lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 09 SE NE SWi 217 ft. 10/16/23 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool .W Driven ❑Dual Rotary ❑Auger Rotary . ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑Other _ r 3017 North Shore Drive,n Orono 55391 DRILLING FLUID WELL.HYDROFRACTURED? ❑Yes .]No Show exact location of well/boring in section grid with"X." Sketch map S ofh weill/borinowinggproperty li location. nes, 1 B n t o n i t e From ft.To ft. N roads,buildings,and direction. USE Domestic ❑Monitoring ❑Heating/Cooling -'I I -I i�q ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial _ �Y ❑Community PWS ❑Dewatering ❑Remedial ❑Elevator ❑ • W ~ E CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. r - T -r T ❑Steel ❑Threaded ❑Welded 'h Mile ®XPlastic ❑ CASING 1 _ „ Diameter Weight Specifications - ;s - c r— 1--1 Mile 4 in.To 213 ft. lbs./ft. 8 in.To 5 6 ft. 6 PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs.ft. •4in.�d2 3 ft. i w. in.To ft. lbs./ft. in.To ft. Swanson Homes OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN y e s • Make johnsop stain e s s From 2 r ft. To ft. j Type Diam. Slot/Gauze •10 Length 8' Set between 213 ft.and 2 1 7 1 ft. FITTINGS 3' 1 C s ri STATIC WATER LEVEL -4 4. ft.30 Below ❑Above land surface Date measured 10/1 6�2 3 Dry hole ❑Yes QJJo WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 7 n0 / i ft.after', ^ 9 hrs.pumping 4 ft q.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION 1 J Pitless/adapter manufacturer Monitor Model I ! 12 in.above grade I ❑Casing protection [� ❑At-grade ❑Well House 0 Hand Pump t^ 1 )` GROUT INFORMATION(specify bentonite,cement-sarfd,neat-cement,concrete,cuttings,or other) ' C1ttin�y`s 213 50 material 6 From To ft. e 1 ❑Yds. ❑Bags Material bent o n i tFr'rom 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 cr c`t 0.Y.Y- ' Top Soil Black S 0 5 Wellis ,f"J�. feet direction from A't\'-le c'1 type ' Well disinfected upon completion? aYes ❑No - Clay/Sand Gray S 5 30 PUMP ❑Not installed Date installed 10/3 0/2 3 Clay/ fine san4 Gray S 30 142 Manufacturer's name existing . Model Number HP Volts Sandy Clay Gray S 142 213 Length of drop pipe existing ft. Capacity g.p.m Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ Sand Gray S 213 223 ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes No VARIANCE Was a variance granted from the MDH for this well? ❑Yes RI No 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 Drifting Co Inc 1691 Licensee Business Name Lic.or Reg.No. Ye14.•" 558 10/30/23Certifie Representative Signature Certified Rep.No.. Date LOCAL COPY 8 7 3 5 30 Name Rob riller Si-odo1 a ID 852603 HE-01205-18(Rev.3/19)