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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 272396 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD SMinnleso aoUnique Well No. <br /> County Nme <br /> Hennepin <br /> Statutes,Chapter 1031 (Leave blew W-serinot es <br /> Township Name Township No. Range No. Section No. Fraction(sm.-0 Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 33 G "6 O 8 <br /> Alt./.5E .E., A f <br /> GPS Latitude degrees minutes seconds Depth Before Sealing al ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> ARUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number andteCity Well or Boring Location ingle Aquifer ❑Multiaquifer513/114.- <br /> �/_ A 1)1 <br /> 95 Willow Dr N Orono WFjLUBORING Measured ❑Estimated Date Measured '[ LY7 <br /> Water-Supply Well ❑Monit.Well r <br /> Show exact location of well or boring Sketch map of well otboring Env.Bore Hole Other 30 ft. elow above land surface <br /> in section grid with"X" location,showing pro rerty ❑ ❑ ❑ <br /> N lines,roads,and buildings-� CASING TYPE(S) <br /> �,, Steel ❑Plastic ❑Tile ❑Other <br /> ---•'r ` ` �r WELLHEAD COMPLETION <br /> t <br /> w E `� <br /> r f--- <br /> T 3 ' Outside: ❑Well House ❑At Grade Inside: Basement Offset <br /> %Mile Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> 1 ❑ <br /> r- --f T-- ❑Buried <br /> S ❑Well Pit <br /> ❑Other <br /> I1 Mile ❑Other <br /> PRQETRTY OW R'S E/COMPANY NAME CASING(S) <br /> eve Diameter t Depth I Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 7 / <br /> in.from to ft. ❑Yes X No ❑Yes ❑No 0 Unknown <br /> 60 Fairway Ridge in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Minnetrista, MN 55364 <br /> in.from to ft. 0 Yes 0 No ❑Yes ❑No 0 Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLEHO,/�I r <br /> Well owner's mailing address if different than property owner's address indicated above Screen from CJ�� to_eq ft. Open Hole from _ to_ ft. <br /> OBSTRUCTIONS <br /> 0 Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill 1 Jo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> Iff not known,indicate estimated formation log from nearby well or boring. ,, <br /> dr J ° J 11 ❑p Removed I of Present ❑Other <br /> i METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 'No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> in.from to ft. 0 Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other ___ _ <br /> GROUTING MATERIAL(S) (One bag of cement=941bs.,one bag of bentonite=50 lbs.) <br /> Grouting Material/114 4 A/ 6 from el, to 21 7 ft. 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? ❑Yes <br /> �`L10 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 Name or Registration No. <br /> / <br /> --1 1) Si.na•e Certified Rep.No. Date <br /> LOCAL COPY H 2723 9 6 �`XI-A r�. <br /> Name of Person Sealing Well or Boring <br /> HE-01434-10 IC#140-0423 5/07R <br />