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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H +f /�20 <br /> WELL OR BORING LOCATION _ ���� AND BORING SEALING RG�OI"ID Sealing No. 1 3 <br /> County Name Minnesota Unique Well No. <br /> Hennepin Minnesota Statutes.Chapter 1031 or W-series No. <br /> iLeeve dank it not known) <br /> Township Name Township No. Range No. Section No. Fraction Ism y Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 0& 21-0.[12 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 905 TonkaWa, Orono Depth Before Sealing M Original Depth '7 _ f <br /> Show exact location of well or boring FF} Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X F( location, showing property ile Aquifer n A <br /> lines,roads,and buildings. g q [-1 Multiaquifer ,;,/ <br /> N x WELUBORING L,O Measured ❑ Estimated <br /> +t Water Supply Well ❑Mont.Well J� <br /> (�^f ❑ Env.Bore Hole ❑Other It below ❑ above land surface <br /> W -- - - -- - -- -- -- E i CASING TYPE(S) <br /> I I <br /> - - -i-- -i-- --i-- :> Steel E] Plastic E]Tile ❑ Other_ <br /> Ylmae <br /> - ---- - i t CASING(S) <br /> ,:.� Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> S � � <br /> �c--- /�4,, Yes o ❑ Yes ❑ No ❑ Unknown <br /> I r mne in.from tom± ft. ❑ -71 <br /> PROPERTY OWNER'S NAME - infrom to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Property owner's mailing address J different than well location address indicated above in.from _ to It. ❑ Yes E]No ❑ Yes ❑ No El unknown <br /> 3436 40th St NE SCREEWOPENHOLE <br /> Buffalo MN 55313 <br /> , Screen from to h. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME <br /> . ❑ Rods/Drop Pipe ❑ Check Valve(s) E] Debris E] Fill ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) `}" f✓ <br /> Obstructions removed? [9/Yes ❑ No Describe <br /> PUMP <br /> Type :! Z , <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> Iii Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> infrom to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 lbs.) <br /> Grouting Material�,i if from to ff. yards _.- bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to_ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes ❑No 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 /> Don Stodola W+ellDrilling Co. , Inc. 27172 <br /> Contrc(or Business me License or Registration rio. <br /> 1-18-00 <br /> Auth zed en ative Signature-" Date <br /> Tien Sterner <br /> JH <br /> 163207 <br /> 6q207 Name of Person Sealing Well or Boring <br />