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—'•` a MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br /> WELL OR BORING LOCATION H ng No. 213824 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota Unique Well 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-s Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 l NW SW veiD 03 <br /> GPS Latitude degrees minutes seconds 2_4 �j <br /> LOCATION: Depth Before Sealing `l ' ft. Original Depth 'w r ft. <br /> Longitude degrees minutes seconds AOUIFER(S) STATIC WATER LEVEL <br /> Numerical� cStreet Address or Fire Number and City of Well or Boring Location Single Aquifer 0 Multiaquifer <br /> 340 Willow Dr Orono (see attached EL %ORING Measured ❑Estimated <br /> 1 ! r Supply Well 0 Monit.Well / <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property 0 Env.Bore Hole 0 Other /U ft. A�below 0 above land surface <br /> N <br /> .. lines,roads,and buildings. 7� <br /> i1 t.y , ( H 4 ' F 1 i1 1 a CASING TYPE(S) <br /> eel ❑Plastic ❑Tile ❑Other <br /> W---r---,----,-----,--•E y211tHEAD COMPLETION <br /> f — — T , ") Outside: 0 Well House Inside: 0 Basement Offset <br /> I I 4 hmiis O XPitless Adapter/Unit 9 Well Pit <br /> It 30 <br /> 9 Well Pit 0 Buried <br /> S <br /> ` J <br /> �tmM <br /> I 1 9 Buried <br /> PROPEREISAN�R'S Nq[NE/COMP��Y lel � 1A CASING(S) <br /> } j �1 _JS�s'i`s>f` j j,� 4 Diameter Depth / Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above <br /> Construction <br /> in.from O t0 7.7 ft. ❑Yes No 0 Yes 0 No 0 Unknown <br /> Mee onstruction <br /> 2000 Ames Dr in.from to ft. ❑Yes 0 No 0 Yes 0 No 0 Unknown <br /> Burnsville, MN 55306 in.from to ft. <br /> ❑Yes 0 No ❑Yes ❑No 9 Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from to ft. Open Hole from_2.7to ,Z4-1,S ft. <br /> OBSTRUCTIONS <br /> Nods/Drop Pipe 0 Check Valve(s) 0 Debris ❑ Fill (Xtlo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 0 Yes ❑ No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> d. .),,,„Type ype` <br /> 0 Removed lot Present 0 Other <br /> G. -'r s 1/-METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> VNo Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> in.from to ft. ❑ 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 cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material N4 4/ ( //f -1/from_Q to yards 2.7 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 XNo 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 Stodola Well Drilling Co., Inc. 27172 <br /> Contractor Business e License or Registration No. <br /> ,/,,- , _ �� � 9-4-03 <br /> A it/d'.resenta ive Sigmail, Date <br /> H 213824 Jim Antonson <br /> LOCAL COPY Name of Person Sealing Well or Boring <br />