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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 1 9/�Q/1 8 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. H j, [,Q[, <br /> County Name Minnesota Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (L•n'.dank Ir not known) <br /> Township Name Township No. Range No Section No. Fraction Ism.-1.Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 31-003f 2.0 rt)rC . 02- <br /> Numerical Street Address or Fire Number and City of Well or Boring Location / <br /> 1214 Wi l dhu r s t En , Orono 55364 Depth Before Sealing /V`_ h Original Depth ! • 5. ft <br /> Show exact location of well or boring - ' Sketch map of well or boring A�L_O,_UIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property ;y�Single Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. P <br /> N WELUBORING Measured ❑ Estimated <br /> ylWater Supply Well ❑Monit.Well �j <br /> -T---T---,-----,--- \ _ 1 T J, J❑' / <br /> Env.Bore Hole ❑Other // I h. below ❑ above land surface <br /> W---r---,---- --^--r--E l f t CASING�/ TYPE(S) <br /> ^-r---I----I -I--- T <.` J` tV Steel ❑ Plastic ❑Tile ❑Other <br /> I I I I <br /> )Smile` ' <br /> --- ---i--- i i- } CASING(S) <br /> fDiameter Depth Set in oversize hole? Annular space initially grouted? <br /> ��L�"""" �,J� ? r/�� / 1( Yes Nilo ❑ Yes ❑No ❑ Unknown <br /> at, t mile--tea / r m.from C,J to ��/! ft. ❑ <br /> OP shWNea NeilE952-472-6955 in.from to ft. ❑Yes ❑No 0 Yes ❑ No 0 Unknown <br /> Property owner's mailing address if different than well location address indicated above. in.from _ to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> C <br /> Screen from /V/ to 1 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/Drop Pipe ❑ Check Valve(s),�❑ Debris �❑j Fill ❑No Obstructionn ,! <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) L.1A" f 2 �,) 4/ ��. 7/,'" <br /> Obstructions removed? [ Yes 0 No Describe <br /> PUMP r Pump <br /> Type j PGA"ff< <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO Removed ❑ Not Present ❑ Other <br /> FORMATION <br /> II 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 /> H <br /> {Jo Annular Space Exists <br /> •I r 1` ) ) J'/-- ❑Annular space grouted with tremie pipe <br /> `' ❑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 /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cementu/ =94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material!'-�/'�04l (. "4/� bbM to /9/5-ft. yards 3 bags <br /> from to ft. yards bags <br /> from to ft. yards bags <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? 0 Yes/�I�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 Stddola Well Drilling Co. ,Inc. 27172 <br /> Contractor <br /> �Business Name License or Registration No. <br /> • <br /> •''rtho red':presentative Signature` - Date <br /> LOCAL COPY <br /> H 192828 Name of Person Sealing Well or Boring <br />