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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H /�q 3825 <br /> WELL AND BORING SEALING RECORD MSeinnesota Uno. ique Well No. �/1 L <br /> County Name " <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank ii 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-- 33 NE SW s,cf, O <br /> GPS Latitude degrees minutes seconds , f <br /> LOCATION: Depth Before Sealing 62 ft. Original Depth 5"4- ft. <br /> Longitude degrees minutes seconds AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location X Single Aquifer 0 Multiaquifer <br /> m Old Crystal Rd, Q� WELL/BORING �1fAeasured 0 Estimated <br /> XXX Crystal.ara Bay ❑Water Supply Well XYMonit.Well f <br /> Show exact location of well or boring Sketch map of well or boring ]� <br /> in section grid with"X" #313.50 (see '(ptrg a�v Env.Bore Hole ❑Other /v��/�� ft. ❑below ❑above land surface <br /> ---r-_-T-N \ � �Pb Ilah}!fs'� CASING TYPE(S) <br /> U( l i i 4 ( i- I I e i it ❑Steel Xlastic ❑Tile ❑Other <br /> W r , , , E + WELLHEAD COMPLETION <br /> • r <br /> f — tv 3'` Outside: 0 Well House Inside: 0 Basement Offset <br /> I • I f I hmife 0 Pitless Adapter/Unit 0 Well Pit <br /> 0 Well Pit 0 Buried <br /> S `t• <br /> I n1s- \ ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME? CASING(S) <br /> PM DI project 2713-75 5 12 Diameter Depth �^) / Set in oversize hole? Annular space initially grouted? <br /> Property owners mailing address if different than well location address indicated above z. # /in.from 0 to 4/ ft. ❑Yes C'No ❑Yes 0 No ❑Unknown <br /> Ames Construction <br /> 2000 Ames Dr in.from to ft. 0 Yes 0 No ❑Yes 0 No ❑Unknown <br /> Burnsville, MN 55306 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 /> � r <br /> Well owners mailing address if different than property owners address indicated above Screen from 8' to f <br /> ft. Open Hole from - to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe 0 Check Valve(s) ❑ Debris ❑ Fill tx No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 0 Yes 0 No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Drift 0 52 Type <br /> 0 Removed X Not Present 0 Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> (kNo Annular Space Exists 0 Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> in.from to ft. 0 Perforated ❑ 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 /> .. <br /> Grouting Material A14"Yr c9JfJ7 from O to 57 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? 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 /> Don Stodola Well Drilling Co., INc. 27172 <br /> Contractor Busi•:ss r•me License or Registration No. <br /> i <br /> / liip <br /> .ii-../' 9-4-03 <br /> •itho�•Representati •Sig ar Date <br /> 213825 Jim Antonson <br /> LOCAL COPY H Name of Person Sealing Well or Boring <br />