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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 329482`�9 4 C� 2 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD SS aliing Na <br /> County Name Unique Well No. L lJ <br /> Hennepin Minnesota Statutes,Chapter 1031 or W W-series No. <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 04 N6 Nei SE 4, AUG 'S <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth Before Sealing /i/ ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or BoringLocation Single Aquifer ❑Multiaquifer <br /> 2715 White Oak Cr1, Orono 5356 `1tjFLUBORING jg Measured ❑Estimated Date Measured snity Vf4/ <br /> .a Water-Supply Well ❑Monit.Well r <br /> Show exact location of well or boring Sketch map of well or boring ❑Env.Bore Hole ❑Oed <br /> ther ft. below ID above land surface <br /> in section grid with"X." location,showing property <br /> ' ds,and bwldings. CASING TYPE(S) <br /> N •of <br /> ':- <br /> _.. <br /> I I ISteel [II Plastic ❑Tile ❑Other <br /> ---j--- --- WELLHEAD COMPLETION <br /> W ' EI T <br /> Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile XPitless Adapter/Unit ❑Buried ❑Well Pit <br /> I I <br /> Ti i €5.,, <br /> ❑Well Pit ❑Buried <br /> S `n. ❑Other <br /> )--1Miley <br /> ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Ste{ie J e, Diameter r Depth ., Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailin� g addh,3s it—different than well location address indicated above ��YY!! in.from 0 to ill ft. ❑Yes X No ❑Yes ❑No ❑Unknown <br /> 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 I <br /> l/ <br /> Well owner's mailing address if different than property owner's address indicated above Screen from ��/ to �� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill XNo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HFROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FOR <br /> FORMATIONMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> ci,L,;ji `/��,Type <br /> O /'V ❑Removed Not Present El Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 'lo 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 /> VARIANCE ,,-,� <br /> Was a variance granted from the MDH for this well? ❑Yes Ig io TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material/vie/4rC.//r=A''rrom Q to if/5" ft. yards 9 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 Bus, ss meLicense or Registration No. <br /> C fie d,4-aimi/ <br /> -we Sign- rr' Certified Rep.No. Date <br /> E <br /> LOCAL COPY H 329 4 8 2 Name of Person Sealing Well or Boring (/ `' "Nr--- <br /> HE-01434-14 IC#140-0423 5/138 <br />