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_ ; MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. + County Name WELL AND BORING CONSTRUCTION RECORD 818 O O�. � Minnesota Statutes,Chapter 10.?I Towns ip e Township No. Range No. Section No. Fraction WELUBOAING DEPTH(completed) DATE WORK COMPLETED y, n. GPS LOCATION—decimal degrees(to four decimal places). �� DRILL WG METHOD Latitude Longitude . �❑Cable Tool ❑Driven I]Auger �Rotary House Number,Street Name,City,and ZIP Code of Well Location i]Other SI7 cC�l� R� ir� OCOTIO 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes o Show exact location of well/boring in section grid with"X:' Sketch map of well/boring loca ?�ntonite From ft.To ft. Showing property I' � roads,buildings,and dire i � USE ` N �Domestic ❑Monitoring ❑Heating/Cooling � ` � � � � Environ.Bore Hole ❑Industry/Commercial --'-- --�------�-- --`-- „j Y Noncommund PWS � *� ❑Community PWS ❑Irrigation ❑Remedial [i'Elevator ❑Dewatering ❑ A, w ; ; ; ; e T CASING MATERIAL Drive Shoe? Yes ❑No HOLE DIAM. --�--- � --�—--.-- ; ------ I Steel �Threaded ❑Welded � '/z Mile f � ❑ � � � � � � � � ' , , , , Plastic ,.. �� r --j-----�-- ---�-- ---�— I CASWG '. 5 L Diameter Weight Specifications �1 Mile� ., in.To�ft. Ibs./ft. �in.To�.q_ft. 1U PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. Ibs./ft. G1. in.To�tt)ft. �r� Zi� '�G�l�lf �.�t� x�4il�� II�• in.To ft. Ibs./ft. o ft. Property owner's mailing address if different than well location\ddress indicated above. SCREEN OPEN HOLE ry Make From ft. To ft. �J52 ?�icmetonka �1V(� Type Diam. � LG��n� ��T �1-771 SIoVGauze Length Set between ft.and ft. FITTINGS STATIC WATER LEVEL Measured from ft. Below ❑Above land surface Date measu �'-- WELL OWNER'S NAME/COMPANY NAME PUMPWG LEVEL(be w land surface) - � �� ft.after � hrs.pumping 5� g.p.m. , Well/boring owner's mailing address if different than pro s d i icated above. WELLHEAD COMPLETION ��r :,. Pitless/adapter manufacture Model ; ❑Casing protection �12 in.above grade (�1'1'Y OF ORONO ❑At-grade ��Well House ❑Hand Pump ' GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Matenal�t��EFrom � To 5V ft. �__ �]Yds. ags Material�t�81 �� 50 To 214 ft. [�Yds. �]BBags HARDNESS OF Material From To ft. n Yds. ❑Bags GEOLOGICALMATERIALS COLOR MATERIAL FROM TO Dnvencasingseal From To __Bags , C�B� �ra�1 ��1;� O � NEAREST KNOWN SOURCE OF CONTAMINATION 1 ��r� �J,� � / _,.1' feet /� direction �-a -��-x-zw`type i r, �} We�l disinfected upon campletion? Yes �j No �i7U brc�m. s�oft l 21 pUMP J'�Not installed Date installed �1�j�� clay/�ancd r+�dd r,�c�fwn 21 41 —�c1�on$ld Manufacturer's name * yravel/�erarx� i 1X C(�r� [}� 1i2 Model Number HP 1�5 Volts_ Length of drop pipe �2�7 R. Capacity g.p.m l�y�� .'ray jtie�� ,1'G Z�8 Type:' Submersible ❑LS.Turbine ❑Reciprocating �Jet ❑ AB D NED WELLS ��Ci�yl 6ravel [Qi,1 TT�(.11j]�'j 12g 212 Does property have any not in use and not sealed well(s)? ❑Yes �No VARIANCE `�gt�� y [E�1t�t1$iLi l.11 243 Was a variance granted from the MDH for this well? ❑Yes No TN# WELI 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,il needed. REMARKS.ELEVATION,SOURCE OF DATA,etc. Stodola Wel Dri � Licensee Business Name Lic.or Reg.No. ? �-' 12-8-15 . .., r ' d re t tive Sig'nature Certified Rep.No. Date Rob StodOla f f. LOCAL COPY 8 18 Q 0 1 - �� Name of Driller ID#52603 HE-o1205-15(Rev.8/13) E