03-27-19 Wel & Boring Construction Record

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MINNESOTA UNIQUE WELL WELL-OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING Na County Name WELL AND BORING CONSTRUCTION RECORD 8 2 7 8 21 Minnesota Statutes,Chapter 1031 TownshipHennepinrvar Township No. Range No. Section No. Fraction(sm.—.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED Orono 117 23 09 ' I' ?+ SB'' 224 3-27-19 _ GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD Latitude Longitude ❑Cable Tool - ❑ even El Dual Rotary frri House Number,Street Name,City,and ZIP Code of Well Location ❑Ougerlotary ii Rotasonic ❑Other 2655 North Shore Dr, Orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes pkgo 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, - roads,buildings,and direction. USE N Domestic ❑Monitoring ❑Heating/Cooling _________ _____________- A O v „,--:.,_,k_,,�,_`g" ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial i - -- -- ElevatornityPWS ❑Dewatering Remedial ❑ ❑ w E • ❑ ❑ T �- CASING MATERIAL HOLE DIAM. Drive Shoe? ❑Yes Ne100 ❑Steel ❑Threaded ❑Welded /Mie >elastic ❑ ____ r ;_ I CASING 77 R Diameter Weight Specifications ) -1 Mile ( 4 in.To 205 ft. lbs./ft. - in.To SOt. PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ff. 63/4 in.To 21St. LSI Custom Homes in.To ft. lbs./ft. in.To ft. SCREEN OPEN HOLE Property owner's mailing address if different than well location address indicated above. 15101 Stone Ridge Trace Make Johnson From ft. To t Wayzata, MN 55391 Type stainless steel Diam. 2“ Slot/Gauze .010 Length 4, .. /_ Set between� �ft.and 214 ft. FITTING$.� 3 1 loader STATIC WATER LEVEL 35 ft.Nr6elow ❑AboveLland surface WELL OWNER'S NAME/COMPANY NAME Measured fromLEVE �Dpte measured 3-Z7i1 J Dry hole El Yes No PUMPING LEVE ow and surface�l G J 190 ft.after 2 hrs.pumping 60 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION ZPitless/adapter manufacturer Whitewater Model Casing protection12 in.above grade ❑At-grade ❑Well House ❑Hand Pump GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) Material_bentonirem 0 To 50 ft. 3 ❑Yds. >63ags Material cutting§rom 50 To205 ft. ❑Yds. ❑Bags HARDNESS OF Material From To ft. ❑Yds. ElBags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag94 lbs.cement Driven casing seal From To Bags or 50 lb .bentonite 1, NEAREST KNOWN SOURCE OF CONTAMINATION /� n clay brown medium 0 14 Well is �/.�5 feet (/t--) direction from C J- &'- e•- Well disinfected upon completion? y Yes ❑No ...i clay gray soft 14 50 PUMP ❑Not installed Date installed 4-15-19 sandy clay gray soft 50 177 Manufacturer's name Schaefer Model Number HP 1.5 Volts 230 clay/sand gray soft 177 204 Length of drop pipe 61 ft. Capacity g.p.m. sand/gravel mix medium 204 215 Type: Submersible ❑L.S.Turbine ❑Reciprocating El Jet ❑ ABA DONED WELLS Does property have any not in use and not sealed well(s)? ❑Yes []�No VARIANCE /` Was a variance granted from the MDH for this well? ❑Yes �lclo 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 SAbdola Well Drilling Co., Inc. 1691 Licensee Business Name Lic.or Reg.No. 5-15-19 ::::4kr",,,e,Wk-,: re Certified Rep.No. Date LOCAL COPY 8 2 7 8 21n..s. e....a_1 Name of Driller ID#52603 HE-01205-16(Rev.5/16)