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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 228583 <br /> County Name <br /> WELL AND BORING SEALING RECORD M nnlenotao.Unique Well No. <br /> ' <br /> HENNEPIN Minnesota Statutes,Chapter 1031 or W-series No. <br /> ( II not ) <br /> Township Name Township No. Range No. Section No. Fraction(sm-Ig) Date Sealed Date Well or Boring Constructed <br /> ORONO 117N 23W 06 /9 OCT. 0 <br /> GPS Latitude degrees minutes seconds y^rte <br /> I <br /> LOCATION: Depth Before Sealing `-�} ft. Original Depth e� ft. <br /> Longitude degrees minutes secondsIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer 0 Multiaquifer <br /> WELL/BORING X1 Measured 0 Estimated <br /> 356 Lake Street W. Orono, Mn. water Supply Well 0 Monit.Well D <br /> Show exact location of well or boring \ Sketch map of well or boring <br /> in section grid with'X' `) location,showing property ❑Env.Bore Hole 0 Other ft. below 0 above land surface <br /> •N ) lines,roads,and buildings. CASING TYPE(S) <br /> a i (Steel 0 Plastic ❑Tile ❑Other <br /> W- E'� <br /> WELLHEAD COMPLETION <br /> I Outside: 0 Well House Inside:�7f Basement Offset <br /> I f I I *mils - 0 Pitless Adapter/Unit 0 Well Pit <br /> 1 <br /> S \ 0 Well Pit ❑Buried <br /> 116—r m.411h ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)T�i NPaO� �E$USE �UI j j'x Diameter Depth f Set in oversize hole? Annular space initially grouted? <br /> Property owns s mai ing a dress'd eren an we oca ion a rens in oa ed above <br /> 3 in.fronO to J I ft. ❑Yes No ❑Yes 0 No ❑Unknown <br /> 4420 Shoreline Drive in.from to ft. <br /> Spring Park, Mn. 55388338 ❑Yes 0 No 0 Yes 0 No 0 Unknown <br /> in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> ( <br /> Well owner's mailing address if different than property owner's address indicated above Screen from.431 to S5 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> XRods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction <br /> Type of Obstructions(Describe),_I,Q /01 a ,,,,,..5:7--- <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed?X Yes 0 No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP (/�� <br /> m <br /> .A ij 'J .... TYPe ` l ut �f Removed ❑ Not Pr sent ❑Other <br /> 'METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �p No Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> /� in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator <br /> 0 Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> +Ct ' r <br /> Grouting Material I nom _to 83cft. 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? 0 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 is <br /> true to the best of my knowledge. <br /> x <br /> i <br /> f DON STODOLA WELL DRILLING CO. , INC. 27172 <br /> Contractor Business Name4.fLicense or Registration No. <br /> • o?:':+rg!�t a ignatu Date <br /> .... LOCAL COPY H 228583 <br /> 1- t.--• `,— <br /> l i -� -,4a"�-_ <br /> Name of Person Sealing Well or Boring <br />