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0/4 STATE OF MINNESOTA DEPARTMENT OF HEALTH <br /> ABANDONED WELL RECORD <br /> I. LOCATION OF WELL MINNESOTA UNIQUE WELL NO. <br /> County Name (leave blank if not known) <br /> Hennepin <br /> r <br /> Township Name Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed <br /> N E k y of y <br /> Orono 118 sr 23 wr 27 SW NE SW 3 ft. / / I i? ' Ci 1 <br /> A <br /> Numerical Street Address and City of Well Location or Distance from Road 5. RRLLLING METHOD (if known) ►�/� 1 1.99). <br /> Intersection j1K1 Cable tool 40 Reverse 70 Drivel`r'1IODug-- <br /> 2225 County Road 6 Orono, MN. . 20 Hollow Rod 50 Air 80 Bored 110 <br /> Show exact location of well 30 Rotary 60 Jetted 90 Power Auger <br /> (in section grid with "0") Sketch map of well location <br /> N 6. OBSTRUCTIONS <br /> • Well obstructed es No <br /> - Obstructions removed Yes 0 No If obstructions cannot be <br /> �iic'I 0 removed, contact MOH <br /> M + - PI(I- E 1 1 before sealing. <br /> ` I T I 7. USE <br /> - X, 4.R CI <br /> Domestic 40 Monitoring 80 Heat Loop <br /> y` ,l�' 20 Irrigation 50 Public 9[] Industry <br /> S 1 / 30 Test Well 60 Municipal HO Commercial <br /> 1 +iL--I 70 Air Conditioning 110 <br /> 2. PROPERTY OWNER'S NAME I Mailing Address if different than 8. CASING(5) <br /> property address indicated above 1114{Black 40Threaded 70 <br /> R & R Excavating 4416 Tonkawood Road 20 Galy. 50 Welded <br /> Minnetonka, MN. 55345 30 Plastic 60 Stainless Steel <br /> HARDNESS OF ,� in. to 139 ft. <br /> 3. FORMATION LOG COLOR FORMATION FROM TO <br /> if not known, indicate formation log from new well or nearby well. in. to ft. <br /> Drift 0 143' 9. SCREEN <br /> 0 Screened well from ft. to ft. <br /> (If known) <br /> 0 Open Hole from ft. to_ ft. <br /> 10. STATIC'WATER LEVE <br /> (c ft. below 0 above <br /> land sur ce Date Measured I I q <br /> 41 I <br /> 11. WELLHEAD COMPLETION <br /> 10 Pttless Adapter t4J Found Buried <br /> 20 Basement offset 50 <br /> "iiiirWell Pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12. GROUTING INFORMATION <br /> Neat Cement 20 Bentonite 30 <br /> Grout 3" Well Approx. 143' deep Grout material from I1(,3toQ ft. cu. yds <br /> 6 Bags Cement <br /> 8 Lbs. Bentonite — — <br /> 2 Men, Labor, Ri and Cement Grout Purr 13. NEAREST SOURCES OF CONTAMINreItN <br /> g P feet direction <br /> type <br /> Well disinfected before sealing? 0 Yes <br /> 14. PUMP Removed 0 Not Present <br /> Type: 1[)Submersible 30 L.S. Turbine 50 Reciprocating <br /> itli(Jet 40 Centrifugal 60 <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and • <br /> active wells in remarks Dec on or on back.) <br /> Other unused well(s) on property? 0 Yes No <br /> Abandoned: 0 Permanent 0 Temporary 0 Not aled <br /> 17. WATER WELL CONTRACTORS CERTIFICATION <br /> This well was sealed under my jurisdiction and this report <br /> is true to the best of my knowledge and belief. <br /> DON STODOLA WELL DRILLING CO. , INC, <br /> Licensee Business Name U""").27172 <br /> icense No.27172 <br /> Address 15306 H . 7 Minnetonka, MN. 55391 <br /> Sign. ,.._. <br /> ign.. . '_.--,..4"..- / Date 1/18/91 <br /> 'ar t•.° a Date 1/18/91 <br /> OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of Driller <br /> IMPORTANT: FILM WITH REND <br />