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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring i�� <br /> WELL AND BORING SEALING RECORD Sealing <br /> No.Unique Well No. H 8 <br /> County Name r <br /> ��{f�p ® j(� Minnesota Statutes,Chapter 1031 or W-series No. <br /> ++'wene 1 Ll Reeve Ul H not k—) <br /> Township Name Township No. Range No Section No. Fraction ism �Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 218 23 1 33 1 33 .000 & <br /> Numerical/Sttreett 7Address or Fire Number and City of Well or Boring Location /74,/ , <br /> 3020 RBtertovn Lid Orono Depth Before Sealing f Original Depth ft <br /> Show exact location of well or boring S,,,ketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X" , cation, showing property Single Aquifer [_1Multiadufer <br /> lines,roads,and buildings. <br /> N WELUBORING Measured ❑ Estimated <br /> Water Supply Well ❑Mond Well OF <br /> ❑ Env.Bore Hole ❑Other !T tt. Abelow ❑ above land surface <br /> W --�- -�-- - -- --i-- E YY � CASING TYPE(S) <br /> tom,/ <br /> -�-- - -�-- --�-- +� ; la[Steel ❑ Plastic ❑Tile ❑ Other <br /> }rimile <br /> _4_ CASING(S) <br /> t <br /> S me �Diaf Depth r Set in oversize hole? Annular space initially grouted? <br /> l <br /> in.from to ft. E] Yes o ❑ Yes ❑ No E] Unknown <br /> PROPERTY OWNER'S NAME in.from to h. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> Pr ng re r non %dicated above. infrom to tt. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> 18340 Minnetonka Blvd /�ff� . <br /> �+ +�+$t+� "1tri'I 55391 �} {•.++ Screen from 1.76 to _ ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/DropPipe p F] Check Valve(s) E] Debris E] Fill X <br /> No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) <br /> Obstructions removed? ❑ Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM I TO ❑ Removed A 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 MOLE: <br /> , y >11K.Annular Space Exists <br /> 0 <br /> P71/ ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to tt. ❑ Perforated ❑ Removed <br /> in.from to tt. ❑ 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 /> ♦� /� �j� ,/�` <br /> Grouting Material jV l-'-��r. tom �.i to LIZ ft, yards rte.+ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to_ tt. 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 /> Don Stodols Well Drilling Co. , Inr_ 27172 <br /> Contractor Busine Name ,.� License or Registration Pao. <br /> r <br /> 12-7-99 <br /> ate,"�'• <br /> 1, <br /> or%WRqpre3&nrat,9rgn pre "' Date <br /> a Jim Antonson <br /> L UL AL :OPS H (�'*y 6 1 4 9 6 Name of Person Sealing Well or Boring <br />