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• <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring �+ A <br /> 0 <br /> WELL OR BORING LOCATION Sealing No. H b <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. r <br /> Hennepin Minnesota Statutes,Chapter 1031 t .5 nir as known) <br /> NoIl <br /> Township Name Township No. Range No. Section No.•Fraction(sm.-s Ig.I Date Sealed Date Well or Boring Constructed <br /> Orono 118N 23W 33 ti N . 20 St P OZ <br /> Numerical Street Address or Fire Number and City of Well or Boring Location `/ / / <br /> 170 Wear Ln N Long Lake, Mn. Depth Before Sealing f / ft Original Depth /GeV h <br /> Show exact location of well or boring 5356 Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property XSingle Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. <br /> N s''�i WELUBORING [Measured CI Estimated <br /> ,1. I , WWater Supply Well ❑Monit.Well f <br /> �~ ❑ Env.Bore Hole ❑Other /7U tt. [below CI above land surface <br /> W'--c--- --'-� E i CASING TYPE(S) <br /> II---i----r--- --- T ,„,1 i Steel ❑ Plastic ❑Tile ❑ Other <br /> I I I I kmue ':,,,.:1 <br /> -t---+---i 1 CASING(S) <br /> ll N l _ Diameter } Depth f Set in oversize hole? Annular space initially grouted? <br /> t mire .� t/in.from `� to /7 ft. ❑ YesNo ❑ Yes ❑No ❑ Unknown <br /> PROPERTY OWNER'S NAME 4 in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Scott Berkey <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑ No 0 Unknown <br /> SCREEN/OPEN HOLE <br /> i <br /> Screen from /C 7 to / t/ ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME ❑ Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill Eo Obstruction <br /> Well owners mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) <br /> Obstructions removed? 0 Yes ❑No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO CIRemoved XNot 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 /> _f >fiNo Annular Space Exists <br /> J . ) k ) /` ,t ❑Annular space grouted with tremie pipe <br /> y. <br /> ❑Casing Perforation/Removal <br /> in.from _ to ft. 0 Perforated 0 Removed <br /> in.from to ft. ❑ Perforated 0 Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> / <br /> Grouting Material A.//r?/ <-</j Nfrom/ /l _/''�,,:_LII to! ' ft. yards > bags <br /> from to//// ���' ft. yards bags <br /> from to . ft. yards begs <br /> from to_ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes ty 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 is <br /> true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING CO. , INC. 27172 <br /> Contractor Business Name License or Registration No. <br /> �. - / = {.te i `- <br /> o zed e`presentative Signature . �-- Oafs <br /> I ! ✓ <br /> O Name of Person Sealing Wall or Boring <br /> LOCAL COPY H <br />