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MINNESOTA UNIQUE WELI <br />WELL OR BORING -OCATION <br />MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br />WELL AND BORING CONSTRUCTION RECORD _ <br />County Name <br />r <br />Ifennenin <br />Minnesota Statutes, chapter 1031 839620 <br />Township Name <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. —+ Ig.) <br />WELUBORING DEPTH (completed) <br />DATE WORK COMPLETED <br />P y <br />n_10-11-19 <br />GPS LOCATION — decimal degrees (to four decimal places). <br />Latitude Longitude <br />DRILLING METHOD <br />❑ Cable Tool ❑ Driven ❑ Dual Rotary <br />❑ Auger Rotary ❑ Rotasonic <br />❑ Other <br />House Number, Street Name, City, and ZIP Code of Well Location <br />799 Old Crystal Fay Rd, Orono 55391 <br />DRILLING FLUID WELL <br />HYD,ROFRACTURED? ❑ Yes 7No <br />water Fro <br />ft. To ft <br />Show exact location <br />of well/boring in section grid with 'X.' Sketch map of well/boring loc i . <br />Showing property I as, <br />N roads, buildings, and dire M) <br />USE Domestic E]Monitoring ❑ Heating/Cooling <br />❑ Noncommunity PWS ❑ Environ. Bore Hole ❑ Industry/Commercial <br />- <br />E] Community PWS I-] E] Remedial <br />w <br />T <br />�—t Mile <br />:__ <br />E 33 <br />h tone <br />s _� <br />Elevator ❑ Dewatering El <br />E] <br />ASING MATERIAL Drive Shoe? ❑ Yes /y�� No <br />Steel Threaded Welded <br />❑❑ <br />Plastic ❑ ❑ <br />HOLE DIAM. <br />in. To SQt. <br />in. To 125, <br />CA SING <br />Diameter 7 Weight Specifications <br />4 in. To 11l ft. Ibs./ft. <br />in. To ft. lbs./ft. <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Streeter his Assoc. <br />in. To ft. Ibs./ft. <br />in. To ff. <br />SCREEN <br />OPEN HOLE <br />Property owner's mailing address if different than well location address indicated above. <br />Make <br />18312 Minnetonka Blvd <br />Dee haven M 55391 <br />Deephaven, <br />From fl. To ft. <br />Type stainless steel Diann., <br />Slot/Gauze .1() Length f 41 ' <br />Set between ft. and h. FITTINGS h f 1pqelpr <br />STATIC WATER LEVEL ft. X Below E] Above land surface <br />/� <br />Date measu 1ed'"(}.1117 Dry hole ❑ Yes No <br />WELL OWNER'S NAME/COMPANY NAME <br />PUMPING LEVEL (below land surface) <br />105 ft. after 3 hrs. pumping 50'f g.p.m. <br />WelUboring owner's mailing address if different than property owners address indicated above. <br />W LLHEAD COMPLETION Whitewater <br />Pitless/adapter manufacturer Model <br />❑ Casing protection 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 entOnit%om To 50 ft. 3 ❑ Yds. XBags <br />Material CUt t in.,4S From _To 111 ft. ❑ Yds. ❑ Bags <br />Material From To ft. ❑ Yds. ❑ Bags <br />Driven casing seal From To _Bags One bag = 94 lbs. cement <br />or 50 lbsbentonite <br />-GEOLOGICAL MATERIALS <br />COLOR <br />HARDNESS OF <br />MATERIAL <br />FROM <br />TO <br />NEAREST KNOWN SOURCE OF CONTAMINATION <br />Clay <br />brown <br />medium <br />0 <br />p <br />1$ <br />Well is .4feet Aj t -i direction from '"0type <br />Well disinfected upon completion? XYes ❑ No <br />clay/sand <br />gray <br />mediuj <br />18 <br />96 <br />PUMP <br />❑ Not installed Date installed 11-6xm 9 <br />Manufacturer's name Schaefer <br />Model Number HP 5 Volts 230 <br />Length of drop pipe ft. Capacity 9 -p.m <br />sandy ealy <br />brown <br />soft <br />96 <br />1103 <br />sand <br />grown <br />soft <br />103 <br />125 <br />Type: oSubmrsible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ <br />ABANDONED WELLS <br />Does property have any not in use and not sealed well(s)? ❑ Yes YNo <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes 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 />Don Stodala Vell Drilling Co,. Inc. 1691 <br />Use a second <br />sheet, it needed. <br />REMARKS, ELEVATION, SOURCE OF DATA, etc. <br />Licensee Lic. or Reg. No. <br />��Bu/sinessa <br />12-5-19 <br />rtifi Representative Signature Certified Rep. No. Dale <br />Rob Stodola <br />LOCAL COPY �839625 <br />Name of Driller <br />ID #52603 <br />1C -U ICVYIf \(IBV. O/IlJ <br />