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WELL OR BORING LOCATION
MINNESOTA DEPARTMENT OF HEALTH AND BORING NO.
WELL AND BORING CONSTRUCTION RECORD
County Name
Hennepin
Minnesota Statutes, chapter 10.91 857044
Township Name
Township No.
Range No.
Section No. Fraction
(sm. — Ig.)
WELL/BORING DEPTH (completed)
DATE WORK COMPLETED
Orono
118
123
27
Sid Sid,, Stf ,,,
267 ""
7/9/21
GPS LOCATION — decimal degrees (to four decimal places).
DRILLING METHOD
Latitude Longitude
❑ Cable Tool ❑ Driven ❑ Dual Rotary
❑ Auger Rotary ❑ Rotasonic
❑ Other
House Number, Street Name, City, and ZIP Code of Well Location
736 Dickey bake Rd Lake MN 55356
DRILLING FLUID WELL
Bentonite From
HYDROERACTURED? ❑ Yes No
ft. To ft.
Show exact location
----------- __
of well/boring in section grid with "X" Sketch map of well/boring location.
Showing property lines,
N roads, buildings, a d- jection.
___L__ ___L__ S
USE K Domestic ❑ Monitoring ❑ Heating/Cooling
❑ Noncommunity PWS ❑ Irrigation ❑ Industry/Commercial
'--- --
W
�j
---F------ I— �T
E
❑ Community PWS ❑ Dewatering ❑ Remedial
❑ Elevator ❑
CASING MATERIAL Drive Shoe? ❑ Yes ® No
HOLE DIAM.
,
r--
�1Mile�
'h Mile T
------ ---- 1
s
Steel E] Threaded E] Welded
Plastic
El®
1.3 in. To 50 ft.
CASING
jDiameter Weight Specifications
"� in. To 257 ft. lbs./ft.
in. To ft. lbs./ft.
6.5 in. To 267ft.
PROPERTY OWNER'S NAME/COMPANY NAME
James Joseph
in. To ft. lbs./ft.
in. To ft.
SCREEN YIN
OPEN HOLE
From ft. To ft.
Property owner's mailing. address if different than well location address indicated above.
same
-
L,�,,,
Make Johnson
N
Type stainless Diam. 2
Slot/Gauze �1f15 H � Length 81 lead �,.,7
Set between 257 ft. and 2 7 ft. FITTINGS 3 lead
STATIC WATER LEVEL 115 ft. X Below ❑ Above land surface
Date measured 7/9/21 Dry hole ❑ Yes EXNo
WELL OWNER'S NAMEICOMPANY NAME
PUMPING LEVEL (below land surface)
250 ft. after 2 hrs. pumping 75 o.p.m.
Well/boring owner's mailing address if different than property owner's address indicated above.
WELLHEAD COMPLETION a
® Pitless/adapter manufacturer IfUteWater Model
❑ Casing protection ❑ 12 in. above grade
❑ Ai -grade ❑ Well House ❑ Hand Pump
GROUT INFORMATION (specify bentonite, cement -sand, neat -cement, concrete, cuttings, or other)
Material cuttings m 257 To 50 ft. ❑ Yds. ❑ Bags
Material nto teFrom— 30—To_7G_ft. —3 E:] Yds. [Bags
Material From To ft. [:]Yds. [:]Bags
Driven casing seal From To _Bags One bag = 94 lbs. cement
or 50 lbs. bentonite
GEOLOGICAL MATERIALS
COLOR
HARDNESS OF
MATERIAL
FROM
TO
NEAREST KNOWN SOURCE OF CONTAMINATION
Clay
brwn
M
0
17
Well isfeet septic direction from SE type
Clay/Sand
Gray
M
17
257
Well disinfected upon completion? ® Yes ❑ No
PUMP
❑ Not installed Date installed 7/13/21
Sand
mix
?S
57
267
Manufacturers name Shafer
1 230
Model Number HP Volts
Length of drop pipe 147 ft. Capacity 10 g.p.m
Type:® Submersible ❑ L.S.Turbine [_]Reciprocating ❑Jet ❑
ABANDONED WELLS
Does property have any not in use and not sealed welf(s)? ❑ Yes ?;No
VARIANCE
Was a variance granted from the MDH for this well? ❑ Yes Pq No TN#
WELL CONTRACTOR CERTIFICATION
Use a second
sheet, if 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.
REMARKS, ELEVATION, SOURCE OF DATA, etc.
Don Stodola Well Drilling, 1691
Licensee Business Name Lic. or Reg. No.
'
Ceftlli d ?es native Signat e Certified Rep. No. Date
LOCAL COPY
1857044
Name of Driller
ID #52603 HE-012ub-le (Hev.3/19)