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MINNESOTA UNIQUE WELL <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH\ AND BORING NO. <br /> County Name WELL AND BORING OQNSTRUCTION}RECORD <br /> Minnesota Status,chapter 1031 :" 87 670 5 <br /> Hennepin ,\ , <br /> Township Name Township No. Range No. Section No. Fraction(sm.--..lg.) WELL/BORING DEPTH(completed) \ DATE WORK COMPLETED <br /> p <br /> Orono 117 23 07 NE NE N1 125 , n 7/12/22 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> ❑Auger r,1 Rotary .❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> DRILLING FLUID WELL HYDROFRACTURED? ❑Yes X No <br /> 860 Windjammer Lanes Oronon + n t <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. From ft.To ft. <br /> Showing property lines, <br /> N roads,buildin s a direction. USE Domestic E Monitoring ❑Heating/Cooling <br /> -__;___•__i___.___� ;___ g ❑Noncommunity PWS Irrigation Industry/Commercial <br /> VY <br /> W ❑ ❑ <br /> • <br /> • <br /> ❑Community PWS ❑Dewatering ❑Remedial <br /> - •---i- -- L 1,F ' ❑Elevator ❑ <br /> w E \ CASING MATERIAL Drive Shoe? ❑Yes [' No HOLE DIAM: ' <br /> T T ❑Steel ❑Threaded ❑Welded <br /> 'h Mile X Plastic ❑ <br /> -- - . ` .. CASING <br /> S ' • Diameter Weight Specifications <br /> 4�----1 Mile I in.To 1 1 ft. lbs./ft. in.T 0 ft. <br /> 6 <br /> 5 <br /> 25 <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs./ft. in.Td ft. <br /> r <br /> in.To ft. _ lbs./ft. in.To ft. <br /> Joe Ziafermann SCREEN OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. <br /> es <br /> Make Ohne From ft. To ft. • <br /> Type Amin es Diam.',� , <br /> Slot/Gauze'''10 Length ' <br /> ' Set between 115 ft.and 125 ft. FITTINGS 3' lead <br /> STATIC WATER LEVEL r /+�+ 89 ft. [xelow ❑Above land surface - <br /> Date measured !/1 2I 22 Dry hole ❑Yes It]No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 110 ft.after 3 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 /> ri Pitless/adapter manufacturer Wh i t ewa t e r Model .. <br /> ❑Casing protection X 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 /> Materia CU t t i f Bom 115 To ❑Yds. ❑Bags <br /> Material entoni om tsg50 To 0 ft' ❑Yds. X Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO Driven casing seal From To Bags One bag=94 lbs.cement <br /> or 50 lbs.bentonite <br /> 1 5 <br /> NEAREST KNOWN SOURCE OF CONTAMINATION C�t A L c r t..J e of"-- <br /> .1 1 Well is feet I direction from (A%ve P 1#'L) type <br /> Brown 15 2 Well disinfected upon completion? X Yes ❑No <br /> Clay PUMP <br /> fir* 287 ❑Not installed Date installed 7I 22! 22 <br /> Clay Manufacturer's name Shafer <br /> Gray S 79 99 Model Number HP ' Volts '�`". <br /> Clay/Sand T Length of drop pipet ft. Capacity g.p.m. <br /> • <br /> gSandrown S 99 125 5 Type:X Submersible ❑L.S.Turbine ❑Reciprocating ❑Jet ❑ <br /> ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? ❑Yes X No <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes ['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 Dr ling 1624" 3 <br /> Licensee Business Name Lic.or Reg.No. <br /> ,,,,,,,,:- ,,,-,k' -,,-,:%4'.- 7/22122 <br /> Bert ilf a Representative Signature Certified Rep.No. Date <br /> LOCAL COPY <br /> Name of Driller <br /> ID#52603 HE-01205-18(Rev.3/19) <br />