12/21/18 Well & Boring Construction Record

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MINNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. County Name WELL AND BORING CONSTRUCTION RECORD 8 2 7 8 3 6 Hennepin Minnesota Statutes,Chapter 1031 Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 06 NW SE SE n. 1/4 1 M GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD ��}-18 Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary ❑Auger Rotary ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location ❑Other_ 4350 Lakeview Crt, Orono 5536,4 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes .NNo Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. water From ft.To ft. Showing property lines, N roads,buildings,and direction. USE Domestic 0 Monitoring ❑Heating/Cooling --- ----_�__ __-__-___i_-- \ ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial ❑Community PWS ❑Irrigation ❑Remedial ------I; -------- --- ❑Elevator ❑Dewatering ❑_ wE T CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. - --: I .\ " ❑SteeI ❑Threaded ❑Weldedd • Y Me lastic -- ' _." -_, CASING & (_,--,1 . uy 'r .•-- Diameter Weight Specifications �—t Mile K,••� C.,..*. 4 n.To 192 ft. lbs./ft. 8 in.To 50n. PROPERTY OWNER'S NAME/COMPANY NAME n.To ft. lbs./ft. 6 z in.To ZOOft. in.To ft. lbs./ft. in.To ft. Norton Homes OPEN HOLE Property owner's mailing address if different than well location address indicated above. SCREEN Make Johnson,,.,,�, 18215 45th Ave Ste D From ft. To ft. N, Type stainless steel Diam.7w Plymouth, MN 55446 Slot/Gauze .010 Length 4$ + /i Set between 1(#2 ft.and 200 ft. FITTINGS 2wx3, leader STATIC WATER LEVEL 76 ft..Below ❑Above land surface Measured from t9� .f dilate measured 20_24_!8 Dry hole ❑Yes ' No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(blow land surface) 185 ft.atZ hrs.pumping 40 q.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION igPitless/adapter manufacturer_Whitewater Model ❑Casing protection x 12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material bentoniteFrom 0 To 50 ft. 3 ❑Yds. Bags Material cuttings From 50 To 192 ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag94 lbs.cement Driven casing seal From To Bags = or 50 lbs.bentonite L 0 NEAREST KNOWN SOURCE OF CONTAMINATION clay brown meeium 25 Well is I feet direction from type 90 SE septic yp Well disinfected upon completion? I Yes ❑No sandy clay gray medium 25 115 PUMP e ❑Not installed Date installed 12-1-18 • fine sand gray soft 115 144 Manufacturer's name Schaefer Model Number HP 1.5 Volts 230 clay/sand brown medium 144 156 Length of drop pipe 105 ft. Capacity g.p.m. sand/claysoft 156 1 Type:$Submersible ❑L.S.Turbine I]Reciprocating ❑Jet ❑ gray ABANDONED WELLS O Does property have any not in use and not sealed well(s)? ❑Yes S'No clay red/brown medium 180 197 VARIANCE .^� Was a variance granted from the MDH for this well? ❑Yes 1'No TN# ravel/sand mix medium 197 200 WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. t'todola Well Drilling Co., Inc• 1691 Licensee Business Name Lic.or Reg.No. 2 e 12-21-13 / i s• -• esen-tativ i lure Certified Rep.No. Date Rob Stodola LOCAL COPY 827836 - Name of Driller ID#52603 HE-01205-16(Rev.5/16)