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4 <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 /> llennepin Minnesota Statutes,chapter 1031 8 3 9 6 1 3 <br /> Township Name Township(Jo. Rang?e,No. <br /> Section No. Fr on(sm.��g.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 LJ' VV ,/.71• ,/ 225 h. 1-6-19 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude 4 Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> A. ❑Auger -(y�Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other �� �-,tI <br /> 4330 Lakeview C , Orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes }[Jo <br /> Show exact location of well/boring in t'lQnyfid:with"X." Sketch map of well/boring location. bentonite From ft.To TT ft. <br /> �i Showing property lines, <br /> N roads,buildings,and direction. USE j��''(Domestic ❑Monitoring ❑Heating/Coaling <br /> y ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> J ❑Community PWS ❑Irrigation 00 <br /> Remedial <br /> ❑Elevator ❑Dewatering ❑ <br /> w E T CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. <br /> 1 <br /> t-- ❑Threaded ❑ elded <br /> Steel <br /> T I/z Mile Plastic ❑ <br /> 1 • CASING <br /> s2'-'t- <br /> Diameter Weight Specifications <br /> I 1 Mile U ___4_in.To_ 215 ft. lbs./ft. in.To_ . <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. bs./ft. in.To Lbs[. <br /> Homes in.To ft. lbs./ft. in.To ft. <br /> Norton OPEN HOLE <br /> Propertyerowner's mailing address if different <br /> than well location address indicated above. SCREEN <br /> Johnson10415 45th ASO N Ste D MakeJohnsonFrom ft. To ft�y�, t� Type stainless Steel Diam. 2w <br /> Plymouth, MN 55446 Slot/Gauze •0 © Length L$ + 4• <br /> Set between /i Vi ft.and ft. FITTINGS�i • 1 <br /> STATIC WATEf3'LEVEL 2i5 [4T <br /> —t— A ft. elow bove and surface <br /> Date measuredl"6 19 Dry hole ❑Yes jgrNo <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 210 ft.air 2 hrs.pumping 3 40 q.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> Pitless/adapter manufacturer Wltirttemster Model <br /> /yy❑Casing protection X12 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 bentonite From 0 To 50 <br /> ft. ❑Yds. [ ags <br /> Material cuttings From To 215 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 /> e� NEAREST KNOWN SOURCE OF CONTAMINATION <br /> clay brown medium /► 24 Well is I %,O feet Edirection from --T type <br /> ��s 82 Well disinfected upon completion? Yes ❑No <br /> clay gray medium 24 PUMP <br /> ❑Not installed Date installed 6-14-19 <br /> clay/gravel gray medium 82 106 Manufacturer's name 9cl'laefer <br /> Model Number HP 1.5 Volts 230 <br /> fine sand brown medium 106 142 <br /> __r l Length of drop pipe 105 ft. Capacity g.p.m. <br /> siltyclay/sand brown medium 142 210 ABANDO ED EiLle ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ��,�� y ABANDONED WELLS <br /> sand/gravel brown medium 210 225 VARIANCEDoes property have any not in use and not sealed well(s)? ❑Yes/ <br /> f No <br /> Was a variance granted from the MDH for this well? ❑Yes 1�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,. Inc. 1691 <br /> Licensee Business Na Lic.or Reg.No. <br /> ":".-F,- 6-19-19 <br /> i Representative Sig ature Certified Rep.No. Date <br /> Rob Stodola <br /> LOCAL COPY 8 3 9 613 Name of Driller <br /> ID#52603 <br /> HE-01205-17(Rev.5/17) <br />