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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 5 5 5 9 5 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD <br /> County Name SealinMinneg Na Unique Well No.Minnesota Statutes,Chapter 1031 or W-series No.(Leave blank;,not known) <br /> Hennepi n <br /> Township Name Township No. Range No. Section No. Fraction(sm.–.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 09 NG? Nt S' ! /e1 i/R <br /> GPS LOCATION–decimal degrees(to four decimal places) r <br /> Depth at Time of Sealing 2 5 7) ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location 'J Single Aquifer ❑Mulliaquifer <br /> WELL/BORING >vleasured Date Measured 5/4 m( b/Y ❑Estimated <br /> 2655 North Shore Dr, Orono 55391 ieWater-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring L! ❑ <br /> in section grid with"X" locatig[showing property ❑Env.Bore Hole El Other ft. ''below above land surface <br /> lines;[4a s,and buil N CASING TYPE(S) <br /> idat.t____ <br /> Steel ❑Plastic El Tile ❑Other <br /> ---;--- ---; --- WELLHEAD COMPLETION <br /> w E T 1---- <br /> �– Outside:''Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> ---h --- <br /> ❑❑WellHouse <br /> ' Ir 3 <br /> u '�`` ❑Well Pit ❑Buried <br /> ; – __, Well Pit <br /> El Other <br /> s ❑Buried <br /> F--1 Mile –I ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> MST (1Rtnm RSG Dia tej i / Depth / Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above in.from O to_230 ft. El Yes , No ❑Yes ❑No El Unknown <br /> 15101 Stone Ridge Trace in.from to ft. ❑Yes ❑No El Yes El No ❑Unknown <br /> Wayzata, MN 55391 <br /> in.from to ft. ❑Yes El No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE , <br /> 2..S9 <br /> Well owner's mailing address it different than property owner's address indicated above Screen from to ft. Open Hole from to ft. <br /> ,OBSTRUCTIONS <br /> pp Rods/Drop Pipe ❑Check Valve(s) CIDebris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)...2/�/#,/1 f_r/ 4 'Cl/7'7i)� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ;(Yes 111No Describe I <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> El Not Present /� <br /> �Present,Removed Prior to Sealing ❑Other <br /> d p,:. ,...k- <br /> "23o Type $OP CUP1'f P <br /> 52L– <br /> ...- . ,g 2s-7 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> yr No Annular Space Exists ['Annular Space Grouted with Tremie Pipe El Casing Perforation/Removal <br /> Casing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? El Yes No TN# <br /> GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) <br /> ,,�y r / <br /> Grouting Materia)4/ i9 C , 7 � from Q to 2531 ft. yards 28 bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS NK <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? El Yes y�No 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 <br /> is true to the best of my knowledge. <br /> Don Stodola hell Drilling Co, Inc. 1691 <br /> Licensee Business Nameff // License or Registration No. <br /> /:.; entBti a rgnature Certified Rep.No. Date <br /> 355595 `ng — , ,` -'� <br /> LOCAL COPY H <br /> Name of Person Sealing Well or Boring <br /> HE-01434-15 ID#53159 (1+ 8/16R <br />