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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD <br /> enn :yn <br /> Minnesota Statutes,chapter 103I 876691 <br /> Township Name Township No. Range No. Section No. Fraction(sm.—••lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED • <br /> Orono 111 23 06 /< SE Sri, 161 ft. 5/18/22 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool 0 Driven ❑Dual Rotary <br /> ❑Auger Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location []Other <br /> 775 Lakeview Parkway Orono DRILLING FLUID WELL HYDROFRACTURED? ❑Yes XI No • <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. Bentoni to From ft.To ft. <br /> Showing property lines, , <br /> roads,,buildings and direction. USE <br /> N g Domestic ❑Monitoring ❑Heating/Cooling <br /> { is ,, � <br /> _ ___,__,___• ;_ ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> " . _..M�....� _ _ ❑Community PWS ❑Dewatering ❑Remedial • <br /> -----•--'---• F-- ❑Elevator ❑ <br /> w E CASING MATERIAL Drive Shoe? ❑Yes X No HOLE DIAM. <br /> -.- --•"- t__ T ❑Steel ❑Threaded ❑Welded <br /> '/ztue <br /> ❑Plastic ❑ <br /> CASING <br /> S Diameter Weight Specifications <br /> I--1 Mile I 45 in.To 153 ft. lbs./ft. go5 in.Tq ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.To ft. <br /> in.To ft. lbs./ft. in.To ft. <br /> Norton Homes OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. SCREEN Yeti <br /> Make Johnson From ft. To ft. <br /> 15 1 45th Ave N Type *AU stainless Diem. 2* <br /> Ste D SloVGauze •10 Length 8 f <br /> -, Plymouth, MN 55446 Set between153 ft.and_I 1 ft. FITTINGS 3* lead <br /> STATIC WATER LEVEL f 7 ft.X Below ❑Above land surface i <br /> Date measured 5/19• '"" Dryhole ❑Yes XNo <br />''' WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> ft.after hrs.pumping g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> X► Pitless/adapter manufacturer used exist i del 9 <br /> ❑Casing protection Z 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 eat t ifl8om 13 To ° ft. ❑Yds. Bags <br /> Materiall3'�fl t 0fh t m �0 To ft. ❑Yds. !Bags <br /> HARDNESS OF Material From_ To _ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR FROM TO <br /> MATERIAL Driven casing seal From To Bags One bag=94 lbs.cement , <br /> or 50 lbs.bentonite . <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> ClayBrown <br /> Well is € feet - direction from , I--»•. type <br /> I Clay 17 Well disinfected upon completion? [ Yes ❑No • <br /> ##Cray38 PUMP �! <br /> ❑Not installed Date installed 7 I /2 <br /> IllayiS T S '" 2 <br /> Manufacturer's name Usedexisting <br /> Model Number HP Volts <br /> Sand Brown S 83 16 <br /> Length of drop pipe Ilse existing ft. Capacity g.p.m. <br /> Type:❑Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes IC No <br /> VARIANCE <br /> I <br /> Was a variance granted from the MDH for this well? ❑Yes aX 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 /> Use a second sheet,if needed. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. <br /> Don Stodoja Well Drilling Co Inc 1691 i <br /> Licensee Business Name Lic.or Reg.No. , <br /> ' A ' ' . <br /> Cert Representative Signature Certified Rep.No. Date <br /> ry1C <br /> ^h�h+ 4 fob Stodola <br /> LOCAL COPY 8 7 6 6 9 1_ Name of Driller 1 <br /> iD#52603 HE-01205-18(Rev.3/19) <br />