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SIAIL UI- MINNLSUTA IJ&AHIMtNI OF H&ALiH <br /> ABANDONED WELL RECORD <br /> 1. LOCATION OF WELL MINNESOTA UNIQUE WELL NO. <br /> (leave blank if not known) <br /> County Name Hennepin <br /> Township Name Township Number Range Number Section No. Fraction 4. WELL DEPTH (completed) Date sealed <br /> N E y yof 4 <br /> Orono 117 or 23 ur 02 NE SE NE 3 ( 0 ft. 3 l 5 / 9 i <br /> Numerical Street Address and City of Well Location or Distance from Road 5. DRILLING METHOD (if known) <br /> Intersection 10 Cable tool 40 Reverse 70 Driven 100 Dug <br /> 1250 Woodhill Avenue, Orono, Minn. X20 Hollow Rod 5D Air 40 Bored 110 <br /> .iry3((Rotary 60 Jetted 9Power Auger <br /> Show exact location of well T` <br /> (in section grid with "X") Sk-t h m.. . w•l location 6. OBSTRUCTIONS <br /> N Well obstructeYes 0 No <br /> L Obstructions re ved Y,es 0 No If obstructions cannot be <br /> removed, contact MOH <br /> _I_ A E before sealing. <br /> , 17. USE <br /> `- • '-'-` - y„i, ,c, 7. <br /> )4 Domestic 40 Monitoring 60 Heat Loop <br /> Lk &�yeu. 20 Irrigation 50 Public 9[] industry <br /> 1 •• Nea�y 30 Test Well 60 Municipal KO Commercial <br /> h'-1 SL A30c'd {moi 11 OVe-, 70 Air Conditioning 11[] <br /> 2. PROPERTY OWNER'S NAME Mailing Address if different than B.'CCA�q A. _\ <br /> S�ING(S) "� <br /> [] <br /> property address indicated above l[ Black 4171 Threaded 7 <br /> 315 East Lake Street T20 Galv. TS[]Welded <br /> Wayzata, Minn. 55391 <br /> Burnet Realty 30 Plastic 60 Stainless Steel <br /> HARDNESS OF in. to j c4. ft. <br /> 3. FORMATION LOG COLOR FORMATION FROM TO <br /> If not known, indicate formation log from new well or nearby well. in. to ft. <br /> 9. SCREEN <br /> De i Fr 61 �/6 yl Screened well froeL ja ft. to.3/c ft. <br /> (If known) <br /> ['Open Hole from ft. to_ ft. <br /> 10. STATfC, 15R LEV ••` <br /> QQ fbelow 0 above <br /> land sur ace Date Measured 3/5 (q/ <br /> 11. HEAD COMPLETION <br /> 1 Pitless Adapter 40 Found Buried <br /> 2(] Basement offset 50 <br /> 30 Well Pit <br /> 16. REMARKS, ELEVATION, SOURCE OF DATA - CASINGS REMOVED, CASINGS PERFORATED, ETC. <br /> 12 ROOTING INFORMATION <br /> Neat Cement 20 Bentonite 30 <br /> Grout material from,liatoQ ft. cu. yds <br /> Grout 4" Well 310' Deep. <br /> 27 Bags Cement <br /> 28# Bentonite 13. NEAREST SOURCES OF CONTAMINATION <br /> _ feet direction type <br /> 2 Men, Rig, Labor & Cement Grout Pump. Well disinfected before sealing? 0 Yes <br /> 14. PUMP Removed 0 Not Present • <br /> Type:)1N)Submersible 30 L.S. Turbine ID Reciprocating <br /> 20 Jet 40 Centrifugal 60 <br /> 15. EXISTING WELLS (Please sketch locations of abandoned and <br /> active wells in remarks sec on or on back.) <br /> Other unused well(s) on property? 0 Yes No <br /> Abandoned: 0 Permanent 0 Temporary 0 N t s led <br /> 17. WATER WELL CONTRACTORS CERTIFICATION <br /> • This well was sealed under my Jurisdiction and this report <br /> is true to the best of my knowledge and belief. <br /> DON STODOLA WELL DRILLING CO. INC. <br /> Licensee Business Name Licens llo.,7 2 <br /> Address 15306 Hi.hwa 7 Mtka, Mn. 5E345 <br /> sign, Date 3-8-91 <br /> Mark Stodola oat.3-8-91 <br /> OFFICIAL ABANDONED WELL RECORD (May be used for Property Transfer) Name of Driller <br /> IMPORTANT: PILE WITH DEED <br /> • 1 <br />