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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 Minnesota Statutes,Chapter 1031 8 2 6 6 7 5 Hnnp(?i n Township NaThe Township No. Range No. Section No. Fraction(sm.—.Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 06 N SW,/SW ,/, 149 n. ,4.21-18 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool 0 Driven ❑Dual Rotary ❑Auger 4 Rotary ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑Other 680 Pinehurst Crt, Orono 55364 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes,No Show exact location of well/boring in section grid with'X." Sketch ma of well/boring location. bentonite From ft.To ft. Showing property lines, N roads,.uildings,and direction. USE Domestic ❑Monitoring ❑Heating/Cooling ' ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ❑Community PWS ❑Irrigation ❑Remedial ❑Elevator ❑Dewatering ❑' w r-l' CASING MATERIAL Drive Shoe? ❑Yea No HOLE ` r 0,- ` ❑Steel DThreads ❑ Welded 'f Miie . Plastic . i--- l � �• � - CASING s _ Diameter Weight Specifications I 1 Mile ( 4 in.To 140 ft. lbs./ft. $_in..Tlo3ft. in.To ft. lbs./ft. 6 . 50 ft. PROPERTY OWNER'S NAME/COMPANY NAME y in Norton Homes in.To ft. lbs./ft. in.To ft. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. Johnson 45th Ave N, Ste D Make Johnson From ft. To ft. Plymouth, MN 55446 Type gtanless ste3 Dim Slot/Gauze .010 Length 41 + 4$ Set between}4—ft.and 1 ft. FITTING STATIC WATER LEVEL 1 t9 i lcadcr OP 70 ftX1 Below ❑Above land surface OP Measured vf Well Date measured 5-21-18 Dry hole ❑YesX'No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 135 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 r•� XPitless/adapter manufacturer Whitewater Model ❑Casing protection '12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material hPntoni teFrom 0 To 50 ft. 3 ❑Yds. IXBags Material cuttings From 50 To 110 ft. ❑Yds. ❑Bags HARDNESS OF Material From To_ ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag94 lbs.cement Driven casing seal From To Bags = or 50 lbs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION QQQ... topsoil black soft 0 4 Well is feet direction from -.j --� type Well disinfected upon completion? '&JJ Yes ❑No clay brown medium 4 20 PUMP p ❑Not installed Date installed 6-7-18 clay gray medium 20 43 Manufacturer's name SCheefer clay/sand Model Number HP 1.5 Volts 230 y gray medium 43 al Length of drop pipe 105 ft. Capacity g.p.m sand/gravel mix medium 81 94 Type:$Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS fine sand gray soft 94 129 Does property have any not in use and not sealed well(s)? ❑Yes V'No f VARIANCE sand/gravel mix medium 129 150 Was a variance granted from the MDH for this well? El Yes>I 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 Drilling Co,. Inc 1691 Licensee Business me rr Lic.or Reg.No. 77-,...„,//.....,' , 7-26-18 sentative Si nature 9 Certified Rep.No. Date Rob Stodola LOCAL COPY 826675 Name of Driller ID#52603 HE-01205-16(Rev.5/16)