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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring rH 148443 <br /> —_ WELL AND BORING SEALING RECORD Sealin No <br /> County Name -- — <br /> Minnesota Unique No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank it not known) '1 <br /> Township Name Township No I Range No Section No. Fraction(sm.i Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono f17 23 08 13-0005 7i -/q/j yS 1. <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> RDepth Before Sealing / ft Original Depth �t / h <br /> 1200 Tonkawad Or <br /> Show exact location of well or boring it Sketch map of well or boringAOl)IFER(S) STATIC WATER LEVEL <br /> in section gnd with"X' location, showing property Single Aquifer ❑ Multiaquifer <br /> lines,roads.and buildings. <br /> N WELUBORING Measured ❑ Estimated <br /> `• Water Supply Well ❑Monit Well i <br /> 1 <br /> E] Env.Bore Hole ❑Other '1710 tt. below <br /> ❑ above land surface <br /> W --�- -T- -i-----T E CASING TYPE(S) <br /> -r- ---' - -- --�-- - feel E] Plastic ❑Tile ❑Other <br /> CASING <br /> Diamet�� Depth Set in oversize hole? Annualar space initially grouted? <br /> S <br /> f mile infrom to /CIO 1. E] Yes [ Jo ❑ Ves ❑No E] Unknown <br /> 1 <br /> PROPERTY OWNER'S NAME infrom to It. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> r, O..-, Dahl Connt-runtinn <br /> Property owner's mailing address If different than well location address indicated abovein.from to tt. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> 100 W Point Rd SCREEN/OPEN <br /> ��HOLE <br /> ''�, r <br /> //�� � <br /> Tonka Bay, 14N 55331 Screen from�to ft Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME <br /> Rods/Drop Pipe El Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> WeII owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) <br /> Obstructions removed? [)f<es ❑ No Describe <br /> PUMP <br /> Type 5(;P: Feu m e <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> If not known,inidicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> WNo Annular Space Exits <br /> Q ❑ Annular space grouted with tremie pipe <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 /> 1 '471 A-1 <br /> GroutingMaterial from lin to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to_ It. 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 XNo 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 /> Jon STodola ;?ell Drilling Co. Inc. 27172 <br /> Contractor Business Name License or Registration Pro. <br /> o RApresentative Signatures...• Date <br /> LOCAL COPY <br /> JH 14 8 4 4 3 Neme of Person Sealing Welf or Boring <br /> HE-01434-03 2197 R <br />