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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring " 324737 <br /> Seal <br /> ng <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnlesso aoUnique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W s erieskNo. <br /> Township Name Township No. Range No. Section No. Fraction(sm.-Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 1 23 08 SV Sq Nle f` / <br /> GPS LOCATION-decimal degrees(to four decimal places) <br /> Depth Before Sealing_ v ft. Original Depth ft. <br /> Latitude Longitude <br /> IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> 1070 Tonkava Road OrocxV W <br /> WE UBORING Measured [:1 Estimated Date Measured <br /> WE <br /> Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X:' location,showing property ❑Env.Bore Hole ❑Other ft. below ❑above land surface <br /> N �, lines,roads,and buildings. CASINGTYPE(S) <br /> rELLHEAD <br /> eel Alastic Tile ❑Other _ <br /> ____ ______ ❑COMPLETION <br /> W E T � Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> h Mile XPitless Adapter/Unit ❑Buried ❑Well Pit <br /> T I <br /> Buried <br /> 1 � <br /> ' xL.t ❑Well Pit ❑ <br /> S ❑Other <br /> —1 Mile ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> DiaDepth f ft. <br /> Charles 1W <br /> r Set in oversize hole? Annular space initially grouted? <br /> ddre <br /> Property owner's mailing ass if different than well location address indicated above in.from a to ❑Yes )lo L]Yes E]No ❑Unknown <br /> 15050 23rd Ave N in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Plymouth, M. 55447 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE OF <br /> Well owner's mailing address if different than property owner's address indicated above Screen from /Uf to 05 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris <br /> ❑Fill /n❑No Obstruction <br /> Type of Obstructions(Describe) ���� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? XYs ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. �`„/� Pump <br /> '}�M(� <br /> Type Lf3 ( r <br /> 64-5 Xemoved ❑Not Present ❑Other <br /> eEjHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ,'��',`',o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. E]Perforated [1Removed <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 do TN# <br /> GROUTING MATERIAL(S) (One bag ofcement=94 lbs.,one bag ofrf bentonite=50 Ibs.) <br /> Grouting Material � tom`/�'- ��from Q , to �ft. yards 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 Xo 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 <br /> is true to the best of my knowledge. <br /> DIM STODOLA WELL DRILLING CO., INC. 1691 <br /> Licensee Business Name License or Registration No. <br /> 558, <br /> rti d Oepresentative Signature Certified Rep.No. Date <br /> LOCAL COPY " <br /> 324737 <br /> Name of Person Sealing Welt or Bo'g <br /> HE-01434-14 IC#140-0423 li 5/13R <br />