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MinnesotaWell and Boring 6 0 93 <br /> CJS` 9 <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH SealinggNNo. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Hennepin Minnesota Statutes.Chapter 1031 or W-series No. • <br /> (Leave blank it not known) <br /> Township Name Township No Range No. Section No. Fraction(sm. •lg.) Date Sealed Approximate Dale Well <br /> Orono 117 23 06 314-- 1 31 OCT c. or Boring Constructed <br /> Numerical Street Address or Fire Number and City of Well or Boring Location a/ <br /> 4580 West Branch Road Orono, Mn. 55364 Depth Before Sealing ea ft. Original Depth � It. <br /> 77��[[ <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level . Accurate <br /> in section grid with'V. location.showing property lines. <br /> ° 41 roads.and buildings. 0 Approximate <br /> N ..�4- <br /> Single TYPAquEder 0 Multiaquifer fl. r below above land surface <br /> 35i <br /> a . -L <br /> W E <br /> 'IT` i <br /> CASING <br /> '.� JCF Steel ❑Plastic 0 Tile ❑Other <br /> S i W I,...)S =^'_ C:..-4\ d. Screen from 7(2, to SV ft. Open Hole from to _— ft <br /> N--r mile—11.1 OBSTRUCTION/DEBRIS/FILL <br /> YObstruction 0 Debris ❑Fill <br /> PROPERTY OWNER'S NAME DaHa <br /> nn<� �r p O <br /> Type of debris/obstruction 7:4.)A)4.--R )rr l 51 atf r <br /> Mailing Address if different than properly address indicated above. <br /> Obstruction/Debris/Fill removed? Yes ❑No <br /> PUMP <br /> ❑Removed ye Not Present 0 Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known.indicate estimated formation log from nearby well or boring. <br /> 3 in.from Q to 743 It. 0 Yes 15(No 0 Yes 0 No ❑Unknown <br /> aC".c•1 © do <br /> in.from to ft. 0 Yes ❑No ❑Yes 0 No 0 Unknown <br /> in.from to ft. ❑Yes ❑No 0 Yes 0 No 0 Unknown <br /> METHOD� USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> ri//No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to - ft. ❑Perforated ❑Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> f <br /> Grouting material A3‘-‘7,-[A/!'J6,t1j from 0 to 63 4 ft. yards 4 bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from . to ft. yards bags <br /> from to ft. yards - bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes Xo <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 /> uth epresentative Signature Date <br /> ,i g;. i ::, H Name of Person Seal Well or Boring <br />