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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I <br /> o. <br /> Count Name <br /> WELL AND BORING SEALING RECORD Minnlesotta Unique Well No. 13 <br /> 796 <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm-)-.Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 11 ON 23W 33 /I j v`/ U <br /> GPS Latitude degrees minutes seconds f 00 <br /> LOCATION: Depth Before Sealing. ft. Original Depth 1ft. <br /> Longitude degrees minutes seconds C UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location 7 Single Aquifer ❑Multiaquifer <br /> WELL/BORING [Measured fl Estimated <br /> ater Supply Well ❑Monit.Well <br /> Show exact location of well or boring 7640 Watertown R.d- T Sketc m"" <br /> well or boring <br /> in section grid with"X" 55356 location,showiM property El Env.Bore Hole ❑Other / ft. )6elow ❑above land surface <br /> lines,roads)dnd buildings. <br /> CASING TYPE(S) <br /> r7CSteel ❑Plastic ❑Tile ❑Other <br /> W -- - - -- - -- -- -- E WELLHEAD COMPLETION <br /> — Outside: ❑Well House Inside: ❑Basement Offset <br /> &mit _ xPitless Adapter/Unit ❑Well Pit <br /> ❑Well Pit ❑Buried <br /> r mrle } h /- �'''_ _. ❑Buried <br /> t - r <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> n1enDiam e� Depth jr Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address di event than well location address indicated above //..�� }}� <br /> in.from V t0/ ft. ❑Yes [ Jo ❑Yes ❑No ❑Unknown <br /> 952-473-2397 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 /> Well owner's mailing address if different than property owner's address indicated above Screen from Z`---to ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill EXo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? E]Yes ❑ No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> t Type <br /> ❑ Removed Not Present ❑Other <br /> _ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> L]�No Annular Space Exists El Annular space grouted with tremie pipe El 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 MATE,RIA/L(S�)+} /^ (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material 1�+�ii T( � m � to�ft. yards —Z-,?,— 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 A. 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 /> DOM STODOLA WELL DRILLING CO., INC. 27172 <br /> Contractor Bus es Name - License or Registration No. <br /> ho d epre entative toe ' Date <br /> t <br /> LOCAL COPY H 1 <br /> Name of Person Sealing Well or B-ring <br />