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WELL MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 266476 <br /> WELL AND BORING SEALING RECORD Minnlesso ao <br /> Na <br /> County Name BORING LOCATION Unique Well No. H <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Here in <br /> (Leave Wank 0-known) <br /> Township Name Township NrRangeNo. Section No. Fraction(sm. Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 1182 32 " '' 3 IL% ' <br /> GPS Latitude degrees minutes seconds Depth Before Sealing /,✓o ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location single Aquifer ❑Multiaquifer 5A/Al– <br /> Water-Supply <br /> �� <br /> 3940 t� W UBORING Measured ❑Estimated Date Measured J <br /> 3940 Watertown Rd Water-Su I Well t <br /> pp y ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring U <br /> in section grid with"X.' location,showing property ❑Env.Bore Hole ❑Other �ft. below above land surface <br /> N lines,roads,and buildings. CASINGTYPE(S) <br /> �V Steel ❑Plastic ❑Tile ❑Other <br /> jj <br /> -- ---`----------------- WELLHEAD COMPLETION <br /> , T <br /> W EI <br /> Outside: L]Well House ❑At Grade Inside: Basement Offset <br /> %Mile ❑Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> -----T---- I Buried <br /> 1 ❑Well Pit ❑ <br /> 1 Mile ❑Other ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Ber NAlding Diarrt�tprr r Depth r Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above t�r //__� <br /> �/ C in.from � to //2m ft. L]Yes No Ll Yes L]No Ll Unknown <br /> 3435 Cty Rd 101 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> linetonka, IST 55345 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE f <br /> s / <br /> Well owner's mailing address if different than property owner's address indicated above Screen from to /3 o ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris [j Fill ❑No Obstruction <br /> Type of Obstructions(Describe)— OF <br /> GEOLOGICAL MATERIAL I COLOR HARDNESS OR FROM TO Obstructions removed? As ❑No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> P <br /> !� Type <br /> � f"� `0 136 VRem ed ❑Not Present ❑Other <br /> U METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 500 Annular Space Exists E]Annular Space Grouted with Tremie Pipe [-]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) AA (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material�sA etc"t 1hrom to ft 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 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 Well Drilling Co., Inc. 1691 <br /> Licensee Business Name i License or Registration No. <br /> e Representative.&) at Certified Rep.No. Date <br /> 266476 <br /> LOCAL COPY " <br /> Name o/Person Sealing Well or Boring <br /> HE-01434-10 IC#140-0423 r 5/07R <br />