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WEl<OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I <br /> WELL AND BORING SEALING RECORD Sealin No. <br /> 9 <br /> County Name 2118195 <br /> Minnesota Unique Well No. <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 ism- Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 32 43,-0007 <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing ft. Original Depth It, <br /> Longitude degrees minutes seconds ApUIFER(S) STATIC WATER LEVEL <br /> Numerical StreettAdddress or Fire Number and City of Well or Boring Location ^Single Aquifer E]Multiaquifer ��..,,// <br /> 3505 > atertom Rd, Orono 55356 WELL/BORING )(Measured ❑ Estimated <br /> )J.7 Water Supply Well [_]Monit.Well f <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property ❑ Env.Bore Hole ❑Other ft. [below ❑above land surface <br /> link,roads,end buiJ�r <br /> N �'..,,i---} �:.J.i_}.�l"-�.c r^- (`._�.." CASING TYPE(S) <br /> )(feel ❑ Plastic ❑Tile ❑Other <br /> �- -�-- -�-- --- WELLHEAD COMPLETION <br /> W E <br /> Outside: ❑Well House Inside: ❑ Basement Offset <br /> -i-- - -- -i-- --i-- <br /> ^"�' XPitless Adapter/Unit ❑Well Pit <br /> ❑Well Pit ❑ Buried <br /> S <br /> r mVe <br /> ❑ Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> st4illen GA9W Dia m tet/ Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above / <br /> in.from�„)- tOfft. E]Yes XNo C]Yes ❑No ❑ Unknown <br /> 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_45]iLL to_f ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris <br /> El Fill ElNo Obstruction <br /> Type of Obstructions(Describe) I NA.1j 0e2 GEOLOGICAL MATERIAL 7 COLOR HARDNESS OR FROM TO Obstructions removed? Yes ElNo Describe ! <br /> FORMATION <br /> If not known.indicate estimated formation log from nearby well or boring PUMP <br /> Type <br /> r Removed ❑ Not Presen Ll Other <br /> _ MET/HOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> I XfVo Annular Space Exists ❑ Annular space grouted with tremie pipe El Casing Perforation/Removal <br /> 7` 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 /> Grouting Material/r+_ - ,i �,f{,(m to-Z Z26t. yards 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 No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed m 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 /> Contract u ame License or Registration No. <br /> onz d epresentative Signah Date <br /> 218125 <br /> LOCAL COPY H f},�_� <br /> Name of Person Sealing Well or Bdiing <br />