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i. . WELL OR BORING LC CATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 205676 County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Hennepin Minnesota Statutes,Chapter 1031 or W-s ek riesot�ownNo. ) — Township Name Township No. Range No. Section No. Fraction(sm-e Ig) Date Sealed Date Well or Boring Constructed Orono 118 23 33 41-0012' 7 l,? 03 rf GPS Latitude degrees minutes seconds �} LOCATION: Depth Before Sealing ft. Original Depth Z 1 ft. Longitude degrees minutes seconds AOUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Numbert� and� City of Well or Boring Location ),/Single Aquifer 0 Multiaquifer 365 Willow Dr N, Orono WE L/BORING [ vleasured ❑ Estimated [Water Supply Well 0 Monit.Well Show exact location of well or boring Sketch map of well or b<ri� f in section grid with"X" s location,showing prope ty 0 Env.Bore Hole 0 Other /O 3 ft. Xelow ❑above land surface r'\ �ines,roads,and buildin)s. r — N 6�� d CASING TYPE(S) 1 teel 0 Plastic ❑Tile 0 Other 9 — W,-- --- ----'--_--'--'E ‘A� WELLHEAD COMPLETION { .. Outside: ❑Well House Inside: 0 Basement Offset I f I I f4mile ,�( Xtess' Adapter/Unit ❑Well Pit IS ❑Well Pit ❑Buried fr.—r mM ' ❑Buried PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) Ingram Excavating Diame Depth t Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above 2 .tet in.from U to Zi`1 ft. 0 Yes 17�`Jo 0 Yes 0 No 0 Unknown 18900 Pioneer Trl 7` Eden Prairie, MN 55344 in.from to ft. ❑Yes ❑No ❑yes ❑No ❑Unknown in.from to ft. 0 Yes 0 No ❑Yes ❑ No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE f� Well owner's mailing address if different than property owner's address indicated above Screen from 2 13 to 2 I ! ft. Open Hole from to ft. OBSTRUCTIONS XRods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction 2 of 2 Type of Obstructions(Descrii....b"e)c.l AJIL/� t ///Y1 Q GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑ No Describe FORMATION If not kn,indicate estimated formation log from nearby well or boring PUMP ``TType 506 Pump 6 lemoved 0 Not Present ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: Annular Space Exists 0 Annular space grouted with tremie pipe ❑ Casing Perforation/Removal in.from to ft. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) (One bag off cementem' =94 lbs.,one bag of bentonite=50 lbs.) Grouting Material L T /�f-"�4(rfm_�to 21'7ft.r yards /8 bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes ''lo How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION f� This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true to the best of my knowledge. Don Stodola We1lDrilling Co. , Inc. 27172 Contractor Business Name --. License or Registration No. / �. !G 03 o•e. -a resentative Signature .- Date LOCAL COPY H 2 l l 5[)7 6 Name of Person Sealing Well or Boring