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It <br /> • <br /> WELL OR BORING LOCATION MINNESOTA UNIQUE WELL <br /> MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING RECORD 792015 <br /> Hennepin Minnesota Statutes,Chapter 1031 <br /> Township Name - Township No. Range No.;; Section No. Fraction • WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 2303. ,W 1NE NW 136 n. 3-22-13 <br /> GPS DRILLING METHOD <br /> LOCATION: Latitude degrees minutes seconds <br /> Longitude degrees -- minutes seconds ❑Cable Tool ❑Driven <br /> jjj Auger ,®,Rotary <br /> House Number,Street Name,City,and ZIP Code of Well Location Fire Number -.,,,. '!'❑Other <br /> 25 Brown Rd S, Orono 55356 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes *Jo <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring lot ation. meter <br /> From ft.To <br /> Showing property lines, ft. <br /> roads,`uifainge,and dir�eYyti. USE mi <br /> N `'�1 Domestic ❑Monitoring ❑Heating/Cooling <br /> ---j------------------ --- ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> ❑Community PWS ❑Irrigation ❑Remedial <br /> ❑Elevator ❑Dewatering ❑ <br /> w ' E �� CASING MATERIAL Drive Shoe? ❑Yes �No HOLE DIAM. <br /> • <br /> • <br /> ❑Steel ❑Threaded ❑Welded <br /> S Miie $Plastic El4- <br /> 1 CASING <br /> s Diameter Weight Specifications <br /> 1 Mile in.To 127ft. lbs./ft. ur.7o <br /> I —� -$-.:' ., Oft <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.To_. ft <br /> Suchmeete (Jolly) in.To ft. lbs./ft. in.To ft. <br /> SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. * ,,.�� <br /> 3103 a'uQg� -u Make On . From ft. To ft. <br /> St ills•r lwWIsod Place Type �ineiC itsl Diam. 2" <br /> St Joseph, 49085 Slot/Gauze .010 Length 42 <br /> ♦ 4. <br /> Mi Set between im ft.and 136 ft. FITTINGS 2"x3' v <br /> STATIC WATER <br /> ikp <br /> Measured from <br /> 77 ft.X3elow ❑Above land surface Date measured 3"22-13 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ` 120 ft.after 3 hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> gPitless/adapter manufacturer dlitetar Model <br /> ❑Casing protection A 12 in.above grade <br /> LI At-grade ❑Well House ❑Hand Pump <br /> GROUTING INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Mate rial_beritordrem_0_To 50 ft. 3 ❑Yds. Aags <br /> Materiae#f ii_50 To 127 ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing sealDriven casing seal From To Bags <br /> trown NEAREST KNOWN SOURCE OF CONTAMINATION,( ^g' <br /> C � 0 17 `� feet /'� direction -� "'—C-' type <br /> Well disinfected upon completion? (es ❑No <br /> sandy clay gray soft 17 113PUMP C_qq <br /> ❑Not installed Date installed 3-25-13 <br /> sand/gravel mix medium 113 136 <br /> —Manufacturer'sSchaefer <br /> • Model Number HP 1 Volts 230qq <br /> • Length of drop pipe 105 ft. Capacity g.p.m <br /> Type:Xiubmersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> • ABANDONED WELLS <br /> • Does property have any not in use and not sealed well(s)? ❑Yes .c 'No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑YesNo 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 /> D011 Stodola Well <br /> '•�i=Dri j Go,. Inc. 1691 <br /> Licensee Business Name {ng S Lic.or Reg.No. <br /> 4-48-13 <br /> C e e r sentative . ature Certified Rep.No. Date <br /> Rob Stodola <br /> LOCAL COPY 792015 <br /> Name of Driller <br /> IC 140-0020 1-1E-01205-13(Rev.11/10) <br />