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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 124608 <br /> WELL AND BORING SEALING RECORD Sealing H <br /> County Name Minnesota <br /> Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Henne in (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-3.-Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 34 % � _`F�� <br /> Numerical Street Address or Fire Number and City of Well or Boring Location / , f <br /> @XXX Wayzata Blvd, Orono Depth Before Sealing 217 /'7 ft. Original Depth 21/7 ft. <br /> Show exact location of well or boring Sketch map of well or ioring �UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing pr perry Single Aquifer ❑ Multiaquifer <br /> lines,roads,and build i gs. >( <br /> N WELUBORING J,3 Measured ❑ Estimated <br /> Water Supply Well ❑Monit.Well <br /> ❑ Env.Bore Hole ❑Other =✓/ <br /> 7 ft. below ❑ above land surface <br /> W -� -� -� -' E CASING TYPE(S) <br /> r <br /> - -- - -- -�-- --�-- Steel ❑ Plastic ❑Tile ❑Other <br /> _j__ - CASING <br /> �^ z Diameter Depth Set in oversize hole? ? <br /> �;',/d. � '4 t�/>f ! P � Annualar space initially grouted <br /> —L in.from to��,� ft. ❑ Yes XNo ❑ Yes ❑No ❑ Unknown <br /> L] E] E]O ERTY OWN 'S NAME in.from to . Yes No ❑ Yes No ❑ Unknown <br /> Rft <br /> ePbers Construction <br /> Property owner's mailing address if different than well location address indicated above. in.from _ to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> 3525 Webster Ave S SCREEN/OPEN HOLE <br /> St Louis Park MN 55416 <br /> Screen from to ft. Open Hole from �` ll': to 2r" <br /> 920-6996 > ft. <br /> OBSTRUCTIOWDEBRIS/FILL <br /> WELL OWNER'S NAME <br /> ❑ Obstruction ❑ Debri:; ❑ Fill No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris'Fill <br /> Obstruction/Debris/Fill removed? ❑ Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed 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 HOLE: <br /> A No Annular Space Exit <br /> p El Annular space grouted with tremie pipe <br /> p l a t v i l l e 218 247- ❑ 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) <br /> Grouting Material N��7! �� f�om G to /J ft. yards <�- bags <br /> from to ft. yards bags <br /> from to h. yards bags <br /> from to_ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> r <br /> Other unsealed well or boring on property? ❑ Yes No <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 Stodola Well Drillin6 Co. , Inc. 27172 <br /> Contractor Business <br /> .,,Name License or Registration No. <br /> 7-10-97 <br /> Authorized Representative Signature Date <br /> im Antonson <br /> LOCAL COPY TH 124608 [Name of Person Sealing Well or Boring <br /> HE-01434-02 10/95A <br />