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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring o. H <br /> County Name <br /> WELL AND BORING SEALING RECORD Sea211995 <br /> Minnesota Unique Well No. <br /> HIMM Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank it nal known) <br /> Township Name Township No. Range No. Section No. Fraction Ism->Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 S <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing //v/'} <br /> ft. Original Depth—/// ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Wl. <br /> Nu eat Address or Fire Number and City of Well or Boring Location Single Aquifer [_1Multiaquifer <br /> L/BORINGeasured E] Estimated <br /> 8V Tonkawa Rd Oro[!© Water Supply Well ❑Monit.Well ` <br /> Show exact location of well or boring Sketch map of well orri <br /> in section grid with"X' location,showing prop ❑Env.Bore Hole ❑Other ft. below ❑above land surface <br /> N lines,roads,and buildii g <br /> CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> W -- - - -- - -- --�-- E WELLHEAD COMPLETION <br /> Outside: ❑Well House Inside: ❑Basement Offset <br /> kmas LJ�Yitless Adapter/Unit E]Well Pit <br /> i --i - 1 / <br /> ❑Well Pit ❑Buried <br /> S <br /> r mae <br /> F-1Buried <br /> P ERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> d ld Diame r/ Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above <br /> 4420 Shoreline Dc /� ,.y �/ <br /> E] ❑ <br /> in.from C./ to_/_06t. E] TT�� <br /> Yes I 0 ❑Yes No Unknown <br /> springy; Park, lit 55384 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑ No ❑Yes ❑ No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> If <br /> / )//��, j <br /> Well owner's mailing address if different than property owner's address indicated above Screen from�to _ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris f❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) /2r,—,l <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? YeS ❑ No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP n <br /> Typedri ft n Ili <br /> / /� <br /> IX"Removed ❑ Not Present ❑ Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> Diel"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 /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of celment=94 Il one bag of bentonite=50 lbs.) <br /> Grouting Material /�� f r~ 1` 0 to `— ft./ yards _4� 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 4NO How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> Ion Stodola Well Drilling Co, Inc. 27172 <br /> Contractor Busines ame License or Registration No. <br /> Oth6eec(ReFp—resenlalive Signature Date <br /> LOCAL COPY H 2119 9 5Jim Antonson - <br /> Name of Person Sealing Well or Boring <br />