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t i. <br /> MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BORING NO. <br /> County Name WELL AND BORING CONSTRUCTION RECORD 810 8 6 8 <br /> Hennepin Minnesota Statutes,Chapter 1031 <br /> Township Name Township No. Range No. Section No. Fraction WELL/BORING DEPTH(completed) DATE WORK COMlR�C Ea,,` _ <br /> Orono 117 23 04 NE NW's SE ,� 122 n. 5-6-1,,5`` vt <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD SEP' — <br /> Latitude Longitude ❑Cable Tool Driven N 2015 <br /> ❑Auger Rotary <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> ®E <br /> 2715 White Oak Crl, Orono 55356 DRILLING FLUID WELL HYDROEDOQ <br /> Show exact location of well/boring in section grid with"X." Sketch mf p of well/boring location. bentonite From ft.To ft. <br /> �o dy Showing property lines, <br /> N ro dings,and direction. USE M Domestic ❑Monitoring ❑Heating/Cooling <br /> ----L ❑Noncommunity PWS ❑Environ.Bore Hole ❑Industry/Commercial <br /> .1' ❑Community PWS ❑Irrigation ❑Remedial <br /> ------- --- ---F --- - ❑Elevator ❑Dewatering ❑ <br /> w E T Drive Shoe? ❑Yes No <br /> CASING MATERIAL 'HOLE DIAM. <br /> ❑Steel ❑Threaded ❑Welded <br /> I.:Mile i , $Plastic ❑ <br /> o CASING <br /> s Diameter Weight Specifications <br /> —1 Miie 4 in.To 116 ft. lbs./ft. _in.Tot. <br /> PROPERTY OWNER'S NAME/COMPANY NAME <br /> in.To ft. lbs./ft. in.To 125t. <br /> in.To ft. lbs./ft. in.To ft. <br /> Steve Jenniges OPEN HOLE <br /> Property owner's mailing a dress if different than well location address indicated above. SCREEN <br /> Make Johnson From ft. To ft. <br /> same Type stainless steel Diam. 2" <br /> Slot/Gauze <br /> •01.0 Length 4' + 4' <br /> _� <br /> STAbetweenTICWAT ft.and 122 ft. FITTINGS <br /> 2"x3* leader v kp <br /> STATIC WATE L <br /> Measured from <br /> 6R ft.❑Below g Above land surface Date measured 5-6-1.5 <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 122 ft.after 2 hrs.pumping 30 g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> f]Pitless/adapter manufacturer it7}'27_tewater Model <br /> ❑Casing protection S 12 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material bentonite�From 00 • To 50 ft. 3 El Yds. 'Bags <br /> Material natural ffr l—50-, 116 ft. ❑Yds. ❑Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLORmediumMATERIAL FROM TO Driven casing seal From To Bags <br /> O NEAREST KNOWN/ SOURCE OF CONTAMINATION� <br /> topsoil black <br /> / O feet /�' direction (1,__9-••-,-4 .—)--'-`Mae— <br /> clay yellow altdium 3 22 Well disinfected upon completion? Yes ❑No <br /> _,/�ti�C o L i- -� • <br /> PUMP <br /> sandy clay gray medium 22 49 ❑Not installed Date installed 5-13-'15 <br /> Manufacturer's name used existing <br /> sand/gravel brown medium 49 122 Model Number HP 1 Volts <br /> 1 <br /> Length of drop pipe !.�1/ ft. Capacity g.p.m <br /> sandy clay red medium 1 22 125 Type:$Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes %No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes igi 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 Busines Name Lic.or Reg.No. <br /> / / 7-28-15 <br /> ertified Representative ignature Certified Rep.No. Date <br /> Rob Stodola <br /> LOCAL COPY 810868 <br /> Name of Driller <br /> IC 140-0020 - HE-01205-15(Rev.8/13) <br />