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MINNFROTA I1N1011FWF11 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. WELL AND BORING CONSTRUCTION RECORDg 4 4 7 91 County Name Hennepin Minnesota Statutes, chapter 1031 Township Name Township No. Range No. Section No. Fraction (sm. —. Ig.) WELL/BORING DEPTH (completed) DATE WORK COMPLETED Orono 117 23 06 S�' S'�;? Sw,, 14p a 11-3-19 GPS LOCATION — decimal degrees (to four decimal places). Latitude Longitude DRILLING METHOD ❑ Cable Tool ❑ riven ❑ Dual Rotary ❑ Auger otary ❑ Rotasonic ❑ Other House Number, Street Name, City, and ZIP Code of Well Location Pineblirst 55364 DRILLING FLUID WELL bentonite From HYDROFRACTURED? ❑ Yes o ft. To ft. Show exact location of well/boring in sec on gri wit Sketch map�f well ring location. ,e hb perly lines, N ✓�= ^^ a "�- ad dirept ! SE Domestic ❑ Monitoring -" ❑ Heating/Cooling y¢ 0 `r ❑ Noncommunity PWS ❑ Irrigation ❑ Industry/Commercial ❑ Community PWS ❑ Dewatering ❑ Remedial ❑ Elevator ❑ w a E T 1� I'� CASING MATERIAL Drive Shoe? ❑ Yes o Q Steel E] Threaded ❑Welded HOLE DIAM. , k Mile l S �— t Mile Plastic ❑ in.To-%)t. 6, in. To 1 -01. CASING Diameter Weight Specifications 4 in. To 140 ft. IbsJft. in. To ft. lbs./ft. PROPERTY OWNER'S NAME/COMPANY NAME Nn r t in. To ft. tbs./ft. in. To ft. SCREEN OPEN HOLE From ft. To ft. Property ownermailing address ddress if different than well location address indicated above. Make Johnson 18215 45th Ave N. Ste D Type stain1pan stl Diarn7~ ly-mouth , tiw 55446 Slot/Gauze -15 Length 41 * 4# Set between =14so= ft. and ft. FITTINGS STATIC WATER LEVEL ft. E] Below ❑ Above land surface n Date measured 11-3-19 Dry hole ❑ Yes ;6No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL (below land surface) 135 ft. after 2 hrs. pumping 35 Q.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION 1 itless/adapter manufacturerModel ❑ Casing protection ;K12 In. above grade ❑ At -grade ❑ Well House ❑ Hand Pump GROUT I FORMATIO (specify bentonite, cement -sand, neat -cement, concrete, cuttings, or other) neqan Material t 0 To ---Q ft. 3 ❑ Yds. Bags Material bet t_ inL�g_From-50—T-. 140 ft. ❑ Yds. ❑ Bags Material From To ft. [jYds. E]Bags Driven casing seal From To Bags One bag = 94 lbs. cement or 50 lbs. bentonite GEOLOGICAL MATERIALS COLOR HARDNESS OF MATERIAL FROM TO topsoil black medium 0 5 NEAREST KNOWN SOURCE OF CONTAMINATION _ Y Well is feet 1t/ direction from type Well disinfected upon completion? JKYes ❑ No lay/sand brown merlium 5 15 PUMP E] Not installed Date Installed1,21 Clay ;)ray rfledium 15 37 Manufacturer's name vone Model Number HP�� Length of drop pipe ft. Capacity 9 -p.m r_1ay/sanfl dray Soft 37 66 sand i'nIx soft 66 87 Type: YSubmersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ ABANDONED WELLS `ine senrj 11rown medium 47 108 Does property have any not in use and not seated well(s)? ❑ Yes o VARIANCE sa 0/ ravel lix Mel iur i 100 150 Was a variance granted from the MDH for this well? E] Yes o TN# WELL CONTRACTOR CERTIFICATION Use a second sheet, it needed. 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. Don Stodola Well Drilling Co. Inc. 1691 REMARKS, ELEVATION, SOURCE OF DATA, etc. Licensee Business Name Lic. or Reg. No. APR 0 3 2020 11-4-19 Cg I'' se to ive S gri " f Certified Rep. No. Date •Rob5torlo1a LOCAL COPY 844791 Name of Driller ID #52603 nwtiwao to d,. u)