10-20-2021 Well & Boring Construction Record

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WELL OR BORING LOCATION ` MINNESOTA DEPARTMENT OF HEALTH MINNESOTA IN END BORINIOG NO.WELLUE A County Name ', WELL AND BORING CONSTRUCTION RECORD 8 6 0 8 2 3 Ale n n e pin Minnesota Statutes,chapter 1031 Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED Urono 117 23 06 ' _4 biE ,.5Y • 125' ft. 10-20-21 GPS LOCATION—decimal degrees(to four decimal places). ,. - - DRILLING METHOD Latitude Longitude - ❑Cable Tool ❑Driven ❑Dual Rotary ❑Auger it Rotary ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑Other Arm Dr 455 Borth Ar Orono. MN - . DRILLING FLUID WELLHYDROFRACTURED? ❑Yes 11 No Show exact location of well/boring in section grid with"X" Sketch map of well/boring location. Bent Onf t \ From ft.To ft. Showing property Imes, N roads,buildings,and direction. USE ®Domestic ' ❑Monitoring ❑Heating/Cooling --?-----i - --- ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial ❑Community PWS ❑Dewatering ❑Remedial i ❑Elevator ❑ W ' E T,:- I ( CASING MATERIAL Drive Shoe? ❑Yes ( No HOLE DIAM. +�—� CI Steel ❑Threaded ❑Welded 'k Miie X Plastic -r .------: 1 ❑ CASING S Diameter Weight Specifications 8 Mile 4 in.To 115 . lbs./ft. LL in.To 50 ft. px_ PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. 6•S in.Ti1 2 ft. SWANSON bUMES in.To ft. lbs./ft. in.To ft. e.9 OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN y r— Make Johnson From ft. To ft. '. 1360 Hamel Road Type stainless Diam. p . hedina, MA 55340 Slot/Gauze •10 +l Length 8t Set betweenl 15 i ft.and 125 5 4eft. FITTINGS 3' lead �' -. STATIC WATER LEVEL 5 J ft. Below ❑Above land surface ~ Date measured 10/20/21 Dry hole ❑ Yes ®No y, WELL OWNER'S NAME/01041"Y NAME PUMPING LEVEL(below land surface) � 110 ft.after 2 hrs.pumping 50 g.p.m. . - Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION liCr'itless/adapter manufacturer Whit eva t e r Model ❑Casing protection _ XI 12 in.above grade - .r;' .. ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Cu 115 50 Materia gSSr., To ft. ❑Yds. ❑Bags Materabent0ni t eom 50 To i„,, ft. ❑-Yds. ®Bags HARDNESS OF Material From To ft. ❑Yds. illBags ` GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement or 50 lbs.bentonite 0 [n1 NEAREST KNO/Wr�URCE OF CONTAMINATION `Clay drown rl ' 14'Well is , J') feet S direction from SP(,1 A C _ type Well disinfected upon completion? ❑Yes ❑No 4V\ Clay/Sand Grey el 14' 8O1PUMP ❑Not installed Date installed 10/26/21 Sand/Grey ,viii S 60' 97' chafer Manufacturer's name Model Number HP 1 1/Ls 2 30 FineSand/Silty Clay;GGaay S 97 '110o 84 Length of drop pipe ft. Capacity . 20 g.p.m. Sand brown S 110 1125'Type:[Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes E No VARIANCE Was a variance granted from the MDH for this well? ❑Yes 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. Coy r� REMARKS,ELEVATION,SOURCE OF DATA,etc. Don St odola Well Drilling C 1691 Licensee Business Name Lic.or Reg.No. Rx ; ', `' ,.� 558 10/26/21 Certified Representative Sign r Certified Rep.No. Date Rob Stodols Wel LOCAL COPY 860823 Name of Driller . ID e52603 HE-01205-18(Rev.3/19)