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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 296348 <br /> Wo. <br /> ELL �'ORING LOCATION WELL AND BORING SEALING RECORD MinnesotaSealinUnique Well No. <br /> County Name <br /> Hennepin Minnesota Statutes,Chapter 1031 Leave a eries No. <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+lg.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 3 tiR 4 / Rf.G II <br /> Latitude degrees minutes seconds /M��/ <br /> GPS g Depth Before Sealing �W ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> i9UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 2120 Webber Hills Rd Orono 55391 L/BORING DieMeasured ❑Estimated Date Measured 5A1Y1c ,0/9/--,[ Vater-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring Env.Bore Hole Other ft. elow above land surface <br /> in section grid with"X." location,showing property ❑ ❑ ❑ <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> x <br /> Steel ❑ ❑Tile ❑Other <br /> T WELLHEAD COMPLETION <br /> w EI <br /> • <br /> } Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> Yr Mile �, ❑Buried ❑Well Pit <br /> 1 .s7 X Pitless Adapter/Unit <br /> - -T- <br /> .- -- ------- <br /> � I ❑Well Pit ❑Buried <br /> s <br /> iZek ❑Other ❑Other <br /> I Mile I <br /> Lz_�Q�.r+O.�- "11-3241--a. <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> - remit Jori Diameter t Depth t Set in oversize hole? Annular space initially grouted? <br /> Property ner's mailing address if different than well location address indicated above q .,- <br /> in.from__ to /94, ft. ❑Yes glo ❑Yes ❑No ❑Unknown <br /> saw 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 /> t <br /> Well owner's mailing address if different than property owner's address indicated above Screen from to 2eiti ft. Open Hole from to ft. <br /> OBSTRUCTIONS ���ttt''' <br /> rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ) o Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> cl Type <br /> ^(/+J{��j` 1:21Z❑Removed X Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> lifNo Annular Space Exists ❑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) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> ./1_f MMI <br /> Grouting Material�t7/ f/7��l.i/ from en to 2 cc)ft. yards e 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 NameLicense or Registration No. <br /> ifi Re resentative Signal Certified Rep.No. Date <br /> LOCAL COPY H 298348 � �� <br /> Name of Person Sealing Well or Boring t� <br /> HE-01434-12 IC#140-0423 9/09R <br />