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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 CONSTRUCTION RECORD 6 0 8 <br /> Hennepin Minnesota Statutes,chapter 103I <br /> Township Name Township No. <br /> Range No. Section No. Fraction(sm.—+lg.) WELUBORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 2 10 SWI, �I, 121 n. 6 t 312 ) <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude , Longitude ❑Cable Tool ❑Driven [Dual Rotary <br /> ❑Auger X Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location ❑Other <br /> • <br /> 1085 Heritage Lane Orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes e 4 No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. Ben t o'ni t e From ft.To ft. 1 <br /> Showing property lines, <br /> N roads,buildings,and direction. USE ®Domestic ❑Monitoring ❑Heating/Cooling <br /> ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial , <br /> 1t} *. ❑Community PWS ❑Dewatering ❑Remedial <br /> --'---• ---� I. ._ -- _ ❑Elevator ❑ <br /> W E t CASING MATERIAL Drive Shoe? ❑Yes X No HOLE DIAM. <br /> T ,fi ,''f ❑Steel ❑Threaded ❑Welded <br /> 7,Mile <br /> i <br /> / \\,,,,, �PlasticCASING <br /> Diameter Weight SpecificationsS ` <br /> 1 Mile { in.To3 ft. lbs./ft. 8 in.To�0 ft.. <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.To ft. lbs <br /> To in.Toft. <br /> Mark 1) Williams in_To ft. lbs./ft. in.To ft. <br /> SCREEN Yes <br /> OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. <br /> Make Dlam. se Q stainless From <br /> '� ft. To ft. <br /> 3�� � Type <br /> Excelsior, MN 55331 SIoUGauze *1 Length 8' <br /> Set between 113 ft.and 121 ft. FITTINGS 3' lead <br /> STATIC WATER LEVEL <br /> ) 44 ft.N Below ❑Above land surface <br /> Date measured 6/ 3/ 2 2 Dry hole ❑ Yes No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 105 ft.after . 2 hrs.pumping 50, g.p.m. <br /> Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION <br /> XPitless/adapter manufacturer bulldog Model <br /> ❑Casing protection "'"° ®12 in.above grade <br /> ❑At-grade ❑Well House 4'❑Hand Pump <br /> GROUT INFORMATION(specify bentonite,cement-sand,neat-cement,concrete,cuttings,or other) <br /> Material C U t t I fl S From 113 To 50 ft. ❑Yds. ❑Bags <br /> Material befl t oni t erom 50 To 0 ft. 3 ❑Yds. [Bags , <br /> HARDNESS OF Material _From___ To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag=94 lbs.cement <br /> Driven casing seal From To Bags <br /> or 50 lbs.bentonite <br /> NEAREST KNOWN SOURCE OF CONTAMINATION ,Is II r`-re 1 <br /> Clay/Sand Brown S 17 Well is t.�J feet _ direction from C-i s 1 � type <br /> Well disinfected upon completion? X Yes ❑No <br /> Clay/Sand Gray M 17 87 PUMP <br /> ❑Not installed Date installed 6/2 3! <br /> Sandy Clay Brown S 87 105 Manufacturer's name Shafer <br /> Model Number HP I•5 Volts 2 3° <br /> Sand/Gravel 9ix S 105 123Length of drop pipe ft. Capacity 20-23 g.p.m. <br /> Type:[Type:4.Submersible ❑L.S.Turbine ❑Reciprocating 0 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 X 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 1691 <br /> Licensee Business Name Lic.or Reg.No. <br /> -/: ' --' �Jy 1 558 / (jy2 <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY 860802 Rt 3 S odo <br /> la <br /> Name of Driller <br /> ID#52603 • HE-01205-18(Rev.3/19) <br />