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• <br /> 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 Minnesota Statutes,chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 23 02 SE SFr six', 170 ft. 3/14/23 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude " ❑Cable Tool ❑Driven ❑Dual Rotary <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other i <br /> 1395 Uecno Lane, Orono DRILLING FLUID ` WELL HYDROFRACTURED? ❑Yes ©No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. Ben t on i t e From ft.To ft. <br /> I Showing property lines, <br /> N roads,buildings,and direction. USE Domestic Monitoring <br /> i i l l <br /> 1.4 <br /> ® ❑ ❑Heating/Cooling <br /> __-i___ i FM ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> ❑Community PWS ❑Dewatering ❑Remedial <br /> -i-- -- ❑Elevator ❑ <br /> w E CASING MATERIAL HOLE DIAM.T x Drive Shoe? ❑Yes g No c <br /> -1---T- '-r <br /> ❑Steel ❑Threaded ❑Welded <br /> Imie <br /> Plastic ❑ <br /> CASING <br /> g - Diameter Weight Specifications r� <br /> • <br /> —t Miley 4 in.To 160 ft. lbs./ft. in.To-5fv ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME n.To ft. lbs./ft. 6. Sin. J 0 ft. ate. <br /> I John Kraemer and Sons in.To ft. lbs./ft. in.To ft. <br /> Property owner's mailing address if different than well location address indicated above. <br /> SCREEN yes OPEN HOLE <br /> Make Johnson From ft. To ft. <br /> 4906 Lincoln Drive <br /> Type stain l e s s Diam.2" <br /> Edina, MN 55436 SloVGauze .1G2 Length 8' • <br /> Set between 1 6 0 ft.and 170 ft. FITTINGS 3' l e a . <br /> STATIC WATER LEVEL 64 ft. Below ❑Above land surface ' <br /> Date measured 6/2 9/2 3 Dry hole ❑Yes No <br />" WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 155 2 40 <br /> ft.after hrs.pumping - q.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION 1 <br /> Pitless/adapter manufacturer Monitor Bu 1 1 1pe i <br />" ❑Casing protection R 12 in.above grade <br /> ❑At-grade ❑-Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite, , <br /> it tcement-sand,neat-cement,concrete,cuttings,or other) <br /> Material Cut t ing'~t'rom 160 To 50ft. ❑Yds. ❑Bags <br /> ' Material e n t Ofl i t' om 50 To 0 ft. 3 ❑Yds. w Bags , <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag94 lbs.cement <br /> Driven casing seal From To Bags = <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION a i r tested <br /> Clay Brown M 0 27 Well is 45 feet south direction from City eT Sewege <br /> .. _ .. _ Well. disinfected.upon'completion?- � --.--Yes -No- .-_-_ .- -,:..�.-- - - - <br /> Clay/Sand Gray S 27 69 PUMP / �� <br /> �" ❑Not installed Date installed 7/ 1 7/2 3 _. <br /> Clay/Gravel Gray M 69 84 Manufacturer's name Shafer �1 <br /> Model Number HP 1 'S Volts 230 <br /> Clay Gray M 84 154 <br /> Length of drop pipe 84 ft. Capacity . g.p.m. <br /> Sandy Clay Bryon S 154 <br /> 54 1 5 8 Type:[Submersible ❑L.S.Turbine ❑Reciprocating El Jet ❑ <br /> ABANDONED WELLS <br /> Sand Mix - S 15 8 1 70 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 ri No TN# <br /> WELL CONTRACTOR CERTIFICATION 4 <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 /> Son Stodoa3. Well Drilling -1691 <br /> t Licensee Business Name Lic.or Reg.No. <br />