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r <br />AAIAIAIFQr) IIAII(II IF IA/FI I <br />WELL OR BORING LOCATION <br />MINNESOTA DEPARTMENT OF HEALTH <br />WELL AND BORING CONSTRUCTION RECORD <br />AND BORING NO. <br />County Name- - <br />Hennepin <br />Minnesota Statutes, chapter 1031 <br />839620 <br />Township Name <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. — Ig.) <br />WELLIBORING DEPTH (completed)DATE <br />WORK COMPLETED <br />I <br />152 <br />403019 <br />Orono <br />117 <br />23 <br />06 <br />SW SW SW,/, <br />GPS LOCATION — decimal degrees (to four decimal places). <br />DRILLING METHOD <br />Latitude Longitude <br />❑ Cable Tool ❑ riven ❑ Dual Rotary <br />❑ Auger _at. Rotary E]Rotasonic <br />E]Other r <br />House Number, Street Name, City, and ZIP Code of Well Location <br />471 O to St Q� 555 " <br />/ 7V`lSketch <br />DRILLING FLUID <br />t� bentonite WELL <br />bentonite <br />HYDROFRACTURED? ❑ Yes No <br />Show location <br />"X."" <br />in map of welWoring I f n. <br />exact <br />of well/boring section grid with <br />Showing proper!_, s, <br />-, x roads, bu'I ' nd dir n. <br />N /' <br />From <br />fl. To ft. <br />USE Domestic ❑Monitoring ❑Heating/Cooling <br />__ ___ __ 5z_ <br />❑ Noncommunity PWS ❑ Environ. Bore Hole ❑ Industry/Commercial <br />_j___ __i__ <br />__ <br />�� <br />❑ Community PWS ❑ Irrigation ❑ Remedial <br />❑ Elevator ❑ Dewatering ❑ <br />W <br />E j <br />CASING MATERIAL Drive Shoe? ❑ Yes No <br />Steel ❑ Threaded ❑ Welded <br />HOLE DIAM. <br />❑ <br />h Mile <br />XPlaslic ❑ <br />Ts <br />- -:-1 <br />CASING <br />Diameter Weight Specifications <br />4 142, <br />8 Soft. <br />�— t Moe <br />in. To lbs./ft. <br />in. To ft. lbs./ft. <br />in. To <br />6'y in. To 152fI. <br />PROPERTY OWNER'S NAME/COJvIPANY NAME <br />Ham" q <br />H <br />Norton ' <br />in. To ft. lbs./ft. <br />in. To ft. <br />SCREEN <br />n <br />OPEN HOLE <br />Property owner's mailing address i different than well location address indicated above. <br />1.8215 45th Ave N, Ste T) <br />Make <br />From ft. To ft. <br />Type stainless Steel Diam. <br />Plymouth, M 55446 <br />Slot/Gauze .010 Length 41 + 41 <br />Set between_ ft. and FITTINGS R t <br />STATIC WATER LEVEL ft."XBelow ❑ Above land surface <br />4-3-19 <br />Date measured Dry hole ❑Yes No <br />WELL OWNER'S NAME/COMPANY NAME <br />PUMPING LEVEL (below land surface) <br />ITS ft. after 2 hrs. pumping Ail g.p.m <br />Well/boring owner's mailing address if different than property owner's address indicated above. <br />WELLHEAD COMPLETION Whitewater <br />Pitless/adapter manufacturer Model <br />❑ Casing protection 112 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 bentoniteFrom 0 T 50 ft. 3 ❑Yds. YBags <br />Material cuttinAS From 50 To 142 ft. [_]Yds. ❑Bags <br />Material From To ft. ❑ Yds. E] Bags <br />HARDNESS OF <br />GEOLOGICAL MATERIALS <br />COLOR <br />MATERIAL <br />FROM <br />TO <br />One 94 s. cement <br />Driven casing seal From To _Bags bag = <br />or 5f) lbs. ben orate <br />NEAREST KNOWN SOURCE OF CONTAMINATION <br />c lay <br />medium <br />_ <br />Welt is 7 feet El direction from type <br />Well disinfected upon completion? Yes ❑ No V. <br />—brown <br />PUMP <br />6�1 S-1 <br />q lay <br />ray <br />medium <br />F-1NotInstalled Date installed <br />ravel San <br />mix <br />Manufacturer's name Schaefer <br />1 <br />Model Number HP 1.0wts 230 <br />r a <br />line sand <br />1. <br />brown <br />soft <br />97 <br />Length of drop pipe 126 ft. Capacity g.p.m <br />Type -)(Submersible E]L.S. Turbine [-]Reciprocating C-]JetE]Sand <br />rSV@1 <br />Mix <br />ABANDONED WELLS <br />Does property have any not in use and not sealed well(s)? ❑ Yes No <br />VARIANCE <br />_ <br />Was a variance granted from the MDH for this well? ❑ Yes No TN# <br />WELL CONTRACTOR CERTIFICATION OF <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 <br />sheet, if needed. <br />REMARKS, ELEVATION, SOURCE OF DATA, etc. <br />Dnn Stodola well Drillin Co,. Inc. 169 <br />Licensee Business Name Lic. or Reg. No. <br />6-19-19 <br />Representative ignature Certified Rep. No. Date <br />er ed <br />Rob Stodola , <br />I <br />LOCAL COPY <br />83962 0 <br />Name of Driller <br />IV ifOZOui <br />