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Q - <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H <br /> RECORD 3 4 4 2 5 J" <br /> WELL OR BORING LOCATION Sealing No. <br /> County Name WELL AND BORING SEALING Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or w seif not ries No. -LL <br /> Hennepin Well or Boring Constructed <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed ..,- <br /> Orono I 117 I 23 09 S#' NV SFT 2.(0 J i9N-' 17 <br /> GPS LOCATION-decimal degrees(to four decimal places) � r ft. <br /> Depth Before Sealing 2_-,e ft. Original Depth <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> WELL/BORING ( Measured ❑Estimated Date Measured.5nmF <br /> 3017 North Shore Dr, Orono Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring ❑Env.Bore Hole ❑Other .3 ft. below ❑above land surface <br /> in section grid with"X" location,showing pro <br /> 1//J lines roa and bw9^ CASING TYPE(S) <br /> N Ai z. o <br /> i Steel 0 Plastic ❑Tile ❑Other <br /> WELLHEAD COMPLETION <br /> ` w E T Outside: ❑Well House ❑At Grade Inside: LI Basement Offset <br /> h Mile �Pitless Adapter/Unit <br /> ❑Buried ❑Well Pit <br /> -Li <br /> T <br /> 7 ❑Buried <br /> j I Well Pit III Other <br /> S <br /> F---1 Mile---') ❑Other <br /> PROPERTY OWNERS NAME/COMPANY NAME CASING(S) <br /> Swanson Hf?f1tPR Diameter,i / Depth/,, / Set in oversize hole? Annular space initially grouted? <br /> Property(ownerZ(Q <br /> s mailing address if different than well location address indicated above ea in.from tn to / ft. ❑Yes to ❑Yes ❑No ❑Unknown <br /> 1360 Hamel Rd in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Medina, MN 55340 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE r <br /> Well owners mailing address if different than property owners address indicated above <br /> Screen from to ft. Open Hole from Awl to 2 7 Q ft. <br /> OBSTRUCTIONS e <br /> 'Rods/Drop Pipe ❑Check Valve(s) ❑Debrisn ❑Fillll ❑No Obstruction <br /> Type of Obstructions(Descr.ibbeL/ft//(i0� /L/_r 4 / UCOP <br /> HARDNESS OR FROM I TO Obstructions removed? *es ❑No Describe <br /> GEOLOGICAL MATERIAL I COLOR I FORNATION '1 <br /> PUMP <br /> If not nown,indicate estimated formation log from nearby well or boring. ��A /� _n, <br /> Type (�tJ <br /> it...>_/ OOslo f wRemoved ❑Not Present ❑Other <br /> 4/ ; 7X METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> to Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes No TN# <br /> GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material//e,47 f I'Ain A.)7 from Q to 777 ft. yards_2.E bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes K'Jo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION 7� <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> don Stodola Well frillin ; Co,. Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> / <br /> ~ //—/ � / <br /> C ifi: 'e,!s- ha Signa l Certified Rep' 10. Date <br /> i <br /> LOCAL COPY H 3 4 4 2 5 Name of Person Sealing Well or Boring <br /> j 5/135 <br /> HE-01434-14 ID#53159 L/ <br />