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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 /> Hennepin iE Minnesota Statutes,chapter 1031 8 7 6 70 8 <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 11.8 23 27 NW NW. SW/4 209 ft- 10/11/2 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> ❑Auger It Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> 11601M/1llow Dr N, Orono DRILLING FLUID WELL HYDROFRACTURED? ❑Yes X]No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. Benton to ,From _ft.To ft. <br /> Showing property lines, <br /> N roads,buildings,and direction. USE lrihr Domestic ❑Monitoring ❑Heating/Cooling <br /> ___ ___ ' ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> ❑Community PWS ❑Dewatering ❑Remedial <br /> ❑Elevator ❑ <br /> w E CASING MATERIAL Drive Shoe? ❑Yes [ No HOLE DIAM. <br /> T ❑Steel ❑Threaded ❑Welded <br /> Y2 Mile ''`" <br /> X Plastic ❑ <br /> 1 1 i CASING <br /> Diameter Weight Specifications <br /> 5I <br /> 1 Mile I f : , 4 in.To 200 ft. lbs./ft. 8 in.To 0 ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. '� in.T ft. <br /> in.To ft. lbs./ft. in.To ft. <br /> Near & Streeter OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. SCREEN Yee' <br /> Make On From ft. To ft. , <br /> -w Type stainlessjilting) _Diem.2 <br /> ,R C 4 r Slot/Gauze *1,d. Length 8* <br /> 2 <br /> Set between ft.and 20 +�ft. FITTINGS .3R* lead <br /> STATIC WATER LEVEL 143 ft.' ]Below ❑Above land surface <br /> Date measured_10; 11'22 Dry hole ❑ Yes /Co <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) • <br /> 195 ft.after hrs.pumping 35 g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> Pitless/adapter manufacturer Monitor bulldog <br /> ❑Casing protection lX12 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 CUt t in $rom 200 To 50 ft. ❑Yds. ❑Bags <br /> Material benton m 50, 0 ft. 3 E Yds. X Bags <br /> HARDNESS OF Material From •To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement , <br /> or 50 lbs.bentonite <br />• <br /> +� 1. <br /> aa NEAREST KNOWN SOURCE OF CONTAMINATION • <br /> Topsoil Back S 0J Well is feet NE <br /> direction from Sewer type <br /> Well disinfected upon completion? [ 'es ❑No <br /> Clay Brown 3 22 PUMP <br /> 11/7/22 <br /> ❑Not installed Date installed <br /> Clay`Sand Gray 135 Manufacturer's name Shafer <br /> Sandy Clay Model Number HP olts 230 <br /> Gravel Dray 14 135 181 168 <br /> Length of drop pipe ft. Capacity g.p.m. <br /> Sandy Clay Brown s iRi 190 Type:L*Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Sand Brown M 190 21 Does property have any not in use and not sealed well(s)? ❑Yes [ No <br /> & VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes X 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 Stodola Well Drilling Co 1691 <br /> • <br /> Licensee Business Name Lic.or Reg.No. <br /> ,x <br /> �-� 558 11/7/22 <br /> Certified`Representative Signature Certified Rep.No. Date <br /> LOCAL COPY 6.6 Rah Stodola <br /> 6 6 Name of Driller <br /> ID#52603 HE-01205-18(Rev.3/19) <br />