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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring w O2^ <br /> WELL OR BORING LOCATION Sealing No. H 1 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. — -- <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank,f not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.i Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 08 13-GO1 ,�� <br /> Numerical Street Address or Fire Number and City of Well or Boring Location �t�( //^. l <br /> 1040 Tonkava Rd, Orono Depth Before Sealing /��/ ft. Original Depth "' _fl <br /> Show exact location of well or boring Sketch map of well or boring $?UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property F��R"Single Aquifer ❑ Mulbaquifer <br /> lines,roads,and buildings. <br /> N � '� WELUBORING Measured ❑ Estimated <br /> Water Supply Well ❑Monit.Well R <br /> ❑ Env.Bore Hole ❑Other t./ ft. ❑below ❑ above land surface <br /> W --------------�-- --i-- E -+' CASING TYPE(S) <br /> z <br /> - -- - -- -i-- -- Steel ❑ Plastic ❑Tile ❑ Other <br /> u mile f! <br /> -- - -- -- -- --'-- CASING <br /> Diameter Depth / J Set in oversize hole? Annualar space initially grouted? <br /> LS 111 /[) <br /> in.from� to� ft. E] Yes XNo El Yes ❑ No � Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> T-aper Romps 473 0314 <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> SCREEWOPEN HOLE <br /> Screen from / to ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill E] No Obstruction y7 <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe),JitI/1 <br /> Obstructions removed? Yes ❑ No Describe <br /> PUMP <br /> Type ,.��..;r� ��m A <br /> GEOLOGICAL MATERIAL 7COLOR HARDNESS OF FROM TO X <br /> 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 /> ' .� t No Annular Space Exits <br /> } ❑ Annular space grouted with tremie pipe <br /> r , <br /> ❑ 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) <br /> Grouting Material lr7t C j� '� from �+ to ft. 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 Stodika Well DRillino Co. , Inc. 21772 <br /> Contractor Business Name License or Registration No. <br /> rt <br /> 'Authorized'Representative Signature Date <br /> All <br /> LOCAL COPY H 134902 Name of Person Sealing Well or Boring <br /> HE-01434-03 2/97 R <br />