05-03-2019 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 3 9 61 9 spin Minnesota Statutes,chapter 1031 Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) WELUBORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 06 SW Sid's SW V. 150 ..r' h_ 5-3-19 GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool ❑ riven ❑Dual Rotary ❑Auger Rotary ❑Rotasonic House Number,Street Name,City,and ZIP Code of Well Location • ❑other ,/ 4775 august* St 55364 DRILLING FLUID WELL HYDROFRACTURED?'❑Yes I,F010 ion of august* A6' J 7Q�i bentonite,:.(. 7" Show exact location of well/borin.in ::'on grid with"X." Sketch map of well/boring location. From ft.To ft. Showing property lines, N roads,buildings,and direction. USEper• ty lin ❑Monitoring ❑Heating/Cooling y____ -QQ.. ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial 4 • ❑Community PWS ❑Irrigation ❑Remedial _-i-...__s_____ �:t-1rt e ❑Elevator ❑Dewatering ❑ w E TrTh^ CASING MATERIAL Drive Shoe? ❑Yes No HOLE DIAM. [1]Steel Weight❑Threaded ❑Welded - 'h Mile %Plastic1 ❑ 1 CASING Diameter Specifications }� i 1 Mile-- 4 in.To 140 ft. lbs./ft. n.To SV ft. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.To ft. Norton Homes in.To ft. lbs./ft. in.To ft. OPEN HOLE Property owner's mailing address if differentthanwell location address indicated above. SCREE U 18215 45th Ave N Ste D Make _! From �•(t. To ft. Plymouth, IN 55446 Type stainless steel Diam. 2" \ Slot/Gauze 1.010 Length 4 # 4' Set between 140ft.and 150 ft. FITTINGS Z y'4 1,ad r STATIC WATER LEVEL p 93 ft.'aelow ❑Above land surface Date measured 5-3-19 Dry hole ❑Yes$No WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 135 ft.after 2 hrs.pumping 40 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ., ❑Pitless/adapter manufacturer Whl towatpr Model ❑Casing protection la 12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUTvINFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material eR nitte From 0/� To 500 ft. 5 ❑Yds. ''Bags Material=tangsFrom 50 To 140 ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ❑Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement or 50 lbs.bentonite NEAREST KNOWN SOURCE OF CONTAMINATION topsoils black soft 0 2j C C, Well is '� feet ..... direction from .`-) type . 3 PUMPisinfected upon completion? Yes ❑No clay brown medium 2 1 n clay gray medium 13 70 ❑Not installed Date installed t+��r 6-14-19 ��1 Manufacturer's name Schafer clay/sand gray medium 70 82 Model Number HP 1.5 Volts 230 Length of drop pipe 126 ft. Capacity g.p.m sand/gravel mix medium 82 99 Type:[Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ sand 99 -ABANDONED WELLS fine sand brown medium 121 Does property have any not in use and not sealed well(s)? ❑Yes 'No L` VARIANCE sand/gravel mix mein 121 150 Was a variance granted from the MDH for this well? ❑Yes 7,*(No TN# 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. Don Stodola Well Drilling Co,. Inc. 1691 Licensee Business Name Lic.or Reg.No. 6-19-19 �..✓ -n Signature Certified Rep.No. Date 8 C Rob Stodola LOCAL COPY 3 9 6 1 9 Name of Driller ID#52603 - HE-01205-17(Rev.5/17)