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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH ,. MINNESOTA UNIQUE WELL AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD Q Q Hennepin Minnesota Statutes,Chapter 1031 V? 3 4 6 V Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 06 ,,M SST 155 h. 3-22-17 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑Driven ❑Auger Rotary House Number,Street Name,City,and ZIP Code of Well Location` El]Other 4705 Augusta St, Orono 55364 DRILLING FLUID • WELL HYDROFRACTURED? ❑Yes I]tNo Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. From ft.To ft. Showing pro erty lines, water roads,buildings, rection. USE N Domestic ❑Monitoring ❑Heating/Cooling __,_____ __, __L -_ / . ❑Noncommunity PWS 111 Environ.Bore Hole IDIndustry/Commercial ,, ❑Community PWS ❑Irrigation 111Remedial ---1-------1.--- __1 : -_ ❑Elevator ❑Dewatering ❑ w ; E CASING MATERIAL Drive Shoe? ❑Yes �No HOLE DIAM. T \ _, ❑Steel ❑Threaded ❑Welded 'h Mie lastic ❑ - - CASING S Diameter L Weight Specifications p n —1 Mile (sr _) 4 in.To 147 ft. lbs./ft. Qp:�—in.To 5°ft. PROPERTY OWNER'S NAME/COMPANY NAME n.To ft. lbs.ft. - in.To 16 Norton Ibmes in.To ft. lbs./ft. in.To ft. OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN 18215 45th Ave N, Ste D Make _ Type stainless steel From fief ft. To ft. Plymouth, M 3 55446 Slot/Gauze .010 Length 4' + 4' ,�,. Set between 147 ft.and 155 ft. FITTINGS 2"a3-' leader STATIC WATER LEVEL Measured from 75 ft. elow ❑Above land surface Date measured 3-22-17 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 1402 r� ft.after hrs.pumping 40 q.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION tom-=tester Pitless/adapter manufacturer Wii2 Model ❑Casing protection j:ir12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material bORntoniterom 500 To 50 ft. 3 ❑Yds. Bags Material cuttings From To 147 ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR FROM TO MATERIAL Driven casing seal From To Bags NEAREST KNOWN SOURCE OF CONTAMINATION clay brown medium 0 21 %'- (9 . feet t j ) direction . 1 +� , �"- type `�'— Well disinfected upon completion? ,Wes E]No \ clay gray medium 21 86 PUMP q LI Not installed Date installed 12- 6-17 silty clay/sand gray soft 86 95 Manufacturer's name .Ci(`hP fPY__ fine sand brown ?!tedium 95 143 Model Number { HP 1.5 Volts 230 1 t C 16Length of drop pipe 105 ft. Capacity g.p.m. water sand brown medium 143 2 Type:,Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes , lo VARIANCE Was a variance granted from the MDH for this well? ❑Yes Alo TN# - WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. Use a second sheet,if needpe The information contained in this report is true to the best of my knowledge. REMARKS,ELEVATION,SOURCE OF DATA.etc. RECEIVED 0 `, Don Stodola Well Drilling Co,. Inc. 1691 APR1 Z018 Licensee Busines Name Lic.or Reg.No. � 1-17-18 CITY OF ORONO �C , e e pr nudge agna ure Certified Rep.No. Date LOCAL COPY 82 3-4 6 H Name of Driller Rob Stodola ID#52603 HE-01205-15(Rev.8/13)