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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 857037 <br /> Minnesota Statutes,chapter 1031 <br /> Hennepin - <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) WELL/BORING DEPTH(completed) DATE WORK COMPLETED <br /> Orono 117 23 04 NW NW NW 123 ft. 9/13/21 <br /> GPS LOCATION—decimal degrees(to four decimal places). DRILLING METHOD <br /> Latitude _ Longitude ❑Cable Tool ❑Driven ❑Dual Rotary <br /> ❑Auger lk Rotary ❑Rotasonic <br /> House Number,Street Name,City,and ZIP Code of Well Location C h El Other <br /> 3195 Watertown kid. Orono 55391 DRILLING FLUID WELL I'WDROFRACTURED? ❑Yes ®No <br /> Show exact location of well/boring in section grid with"X." Sketch map of well/boring location. water „.';''' '"g ft.To ft. <br /> Showing property lines, <br /> roads,buildings,and direction. USE <br /> IllHeating/Cooling <br /> ----I-----1-----L------1--- Gi t.{,s,--*o w--).N ( %4' ❑Noncommunity PWS ❑Irrigation ❑Industry/Commercial <br /> ❑Community PWS ❑Dewatering ❑Remedial <br /> f ❑Elevator ❑ <br /> w E CASING MATERIAL Drive Shoe? ❑Yes ®No HOLE DIAM. <br /> . . ' T �( <br /> ®❑Steel 1 Threaded ❑Welded <br /> M <br /> /z il¢ Plastic <br /> III--1------F-----i--- <br /> % 1 CASING <br /> s —S Diameter 1 b Weight Specifications <br /> -- <br /> F1 Mn¢ *-- ”— 4 in.To 114 4 ft. lbs./ft. 8 in.To 50 ft. <br /> in.To ft. lbs./ft. 6.5 in.Tot24ft. <br /> PROPERTY OWNER'S NAME/COMPANY NAME -- <br /> Beth Tkautiii$n in.To ft. lbs./ft. in.To ft. <br /> Yes OPEN HOLE <br /> Property owner's mailing address if different than well location address indicated above. SCREEN <br /> Make johnson From �y ft. To ft. <br /> same Type stainless Diam. 2" <br /> SloVGauze •10xLength 8 1 <br /> Set between 114 ft.and 123 ft. FITTINGS 3" I ead <br /> STATIC WATER LEVEL 77 ft.z[j Below ❑Above land surface <br /> Date measured 9. 1 3/2 1 Dry hole ❑Yes gl No <br /> WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) <br /> 110 ft.after 2 hrs.pumping 40 g.p.m. <br /> I Well/boring owner's mailing address if different than property owners address indicated above. N/ELLHEAD COMPLETION r k`irtu <br /> ""- Pitless/adapter manufacturer(i(� Model <br /> ❑Casing protection ` 42 in.above grade <br /> ❑At-grade ❑Well House ❑Hand Pump <br /> GROUT INFORMATION(specifyci�fyqbentonite,tcement-sand,` neat-cement,concrete,cuttings,or other) <br /> li Material �'U t t i n mm 1 I To 6g ft. ❑Yds. ❑Bags <br /> Materia( be n t o n i t , 50 To ft. 3 ❑Yds. Q Bags <br /> HARDNESS OF Material From To ft. ❑Yds. ❑Bags <br /> GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO One bag94 lbs.cement <br /> Driven casing seal From To Bags = <br /> or 50 lbs.bentonite <br /> 1 NEAREST KNOWN SOURCE OF CONTAMINATION <br /> top soil b 1 k in O Well is feet _ direction from type <br /> Well disinfected upon completion? �]Yes ❑No <br /> clay brwn it 4 12 PUMP <br /> ❑Not installed Date installed 11 13,;.1 a ( <br /> clay/sand gray a 12 85 <br /> Manufacturer's name <br /> 97 i Model Number HP 112 Volts 3 <br /> sandy/clay brown g 85 <br /> 7 Length of drop pipe O 1 ft. Capacity 0 g.p.m <br /> sand brown s 97 125 Type:NtSubmersible ❑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 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 Business Name Lic.or Reg.No. <br /> 558 9/13/21. <br /> �a�fl1 dd epresent 'e Signature Certified Rep.No. Date <br /> g°b Stodola <br /> LOCAL COPY <br /> 857037 <br /> Name of Driller <br /> ID#52603 HE-01205-18(Rev.3/19) <br />