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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H213 213826 <br /> Sealing <br /> County Name <br /> WELL AND BORING SEALING RECORD Minneso aoUnique Well No. c 3 <br /> Hennepin Minnesota Statutes,Chapter 1031 o aW -seve blank,riest not kNo. <br /> Township Name Township No. Range No. Section No. Fraction(sm>Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 24 VW SW .,/ , ./._/) b <br /> GPS Latitude degrees minutes seconds �+ Q <br /> LOCATION: Depth Before Sealing ! , ft. Original Depth 3 I , ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Nume'al Street Ad r ss or Fire NuerandmbCity of Well or Boring Location Dingle Aquifer ❑Multiaquifer <br /> 'Ai �� WELL/BORING <br /> ❑Water Supply Well (M ❑ <br /> easured Estimated <br /> #3t►.)o see atfacFied sheet} <br /> [ vlonit.Well r <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 2C ft. below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> alp 0 Steel [11Plastic ❑Tile 0 Other <br /> W E -\ P O. WELLHEAD COMPLETION <br /> Outside: ❑Well House Inside: 0 Basement Offset <br /> I I t hmils <br /> ❑Pitless Adapter/Unit ❑Well Pit <br /> +---I 1--- 1 <br /> +,, 0 Well Pit ❑Buried <br /> I S <br /> I4 t mM-4 •`- <br /> 0 Buried <br /> lirbyrri ry;gLIt O Yq�1VE, CASING(S) <br /> J j ,T� j+=©J"`�'� r <br /> 75 12 Diameter Depth 0, Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above r/in.from Oto 3c ft. 0 Yes No ❑Yes ❑No ❑Unknown <br /> Ames Constvrction <br /> 2000 Ames Dr in.from to ft. 0 Yes 0 No 0 Yes 0 No ❑Unknown <br /> Burnsville, MN 55306 in.from to ft. ❑Yes ❑No ❑Yes 0 No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r <br /> Well owner's mailing address if different than property owners address indicated above Screen from ?S to .-1 S / ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe 0 Check Valve(s) ❑ Debris 0 Fill ljNo 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 /> Type <br /> drift 0 39 0 Removed ck,Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XNo Annular Space Exists ❑ Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. 0 Perforated ❑ 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 /U�47 c4/7-g-A/from to 35 tt. yards _____I 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 ❑❑lo 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 Busines 'ame License or Registration No. <br /> mal <br /> ..,;.4"0"5 representative Sig Oft 'e Date <br /> LOCAL COPY H 213826 Jim Antonson <br /> Name of Person Sealing Well or Boring • <br />