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r ll MINNESOTA DEPARTMENT OF HEALTH Minnesota Weand Boring A .� <br /> WELL OR BORING LOCATION _ - WELL AND BORING SEALING RECORD sealing No i H 1 {Th61897 <br /> �II <br /> County Name Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin (L...U-xitr.k „r) L -- <br /> Township Name Township No. Range No. Section No. Fraction Ism.-►Ig) Date Sealed Date Well or Boring Constructed <br /> Orofl0 118 23 33 33-000 C- <br /> Numerical Street Address or Fire Number and City of Well or Boring Location r <br /> 3020 Watertown Rd Orono Depth Before Sealing�_ n Original Depth 815' _h <br /> Show exact location of well or boring Sketch map of well or boring OUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". S location, showing properly Ingle Aquifer ❑ Mulhaquifer <br /> n -1 ln-iduo <br /> N WELL/BORING Measured ❑ Estimated <br /> Water Supply Well ❑Monit.Well <br /> ❑ Env.Bore Hole ❑Other If 14 below ❑ above land surface <br /> yyy_ t CASING TYPE(S) <br /> 3� F <br /> -;-- -;" --;-- --;-- Steel ❑ Plastic E]Tile ❑ Other <br /> )"mile - <br /> -- _-(-- <br /> CASING(S) <br /> ' Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> $ <br /> 41 <br /> I <br /> in.from to ft. ❑ Yes No ❑ Yes E]No ❑ Unknown <br /> k f i a.As✓.�Jr�+.. ��.. <br /> PROPERTY OWNER'S NAME infrom to h. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Steiner & Koppelman <br /> Property owner's mailing address If different than well location address indicated above. in.from _ to If E] Yes E]No ❑ Yes ❑No E] Unknown <br /> 18340 Minnetonka Blvd SCREEN/OPEN HOLE <br /> �,, <br /> 55391 <br /> � t <br /> W$yz a t t) Hl�N�T l 5 39 1 Screen from_ " L-—_to_ 403 It Open Hole from to tt. <br /> 7 <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME VRods/Dro Pie Check Valves Debris Fill <br /> p p ❑ ( ) ❑ f❑ ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) „,6�C'j;/� �.A� Q- 4Cp1-n &(X <br /> Obstructions removed? AYes ❑ No Describe <br /> PUMP ��/ <br /> Type 5(TIc-/e_G KF— Of.4 rOr <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 /> A(N[o Annular Space Exists <br /> /❑"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) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> ny'' yip ' T i <br /> Grouting Material A14=19 jQE h-' om 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 WNo 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 Well Drilling Co. , Inc. 27172 <br /> Contractor Business Na - License or Registration Itio. <br /> 12-7-99 <br /> Sdn.ire Date <br /> Jin Antonson <br /> LOCAL COP H 161897 Name of Person Sealing Well or Boring <br />