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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H. 31202 3 WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Minnesota o aUnique Well No. County Name Minnesota Statutes,Chapter 1031 orr W s eries No wno. Hennepin Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed Orono 117 23 93 NW SW SE 8 mew /.3 , GPS Latitude degrees minutes seconds Depth Before Sealing 7v ft. Original Depth ft. LOCATION: Longitude degrees minutes seconds ��A��O{[UIFER(S) STATIC WATER LEVEL Nurt1561jree � iF6tpu retiat of We4ifer g'lattigglo WELLngle/BORING Nuifer ❑Multiaquifer Measured ❑Estimated Date Measured .5.9lYIc I�YQ}J L]1�A bT.....U C•t�..r.. acLLdds�Cr^LLddIIl/�� vt U 5 5 364 'Water-Supply Well ❑Monit.Well / Show exact location of well or boring Sketch map of well or boring ,—, Bore Hole SC below ❑above land surface in section grid with"X." location,showing property ❑ ❑Other H. in:.,roadsa .buildu N r r . CASING TYPE(S) XSteel ❑Plastic ❑Tile ❑Other ---',-----+-----f------- WELLHEAD COMPLETION W ET ,() Outside: ❑Well House ❑At Grade Inside: Basement Offset 'h Mile ❑Pitless Adapter/Unit ❑Buried ❑Well Pit --- --r- 1. 11 :10 Well Pit ❑Other F t Mile I ❑Buried S ❑Other PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) J Scotty Builders Diameter/ _ Depth�y r Set in oversize hole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above C//// in.from S F to /2 ft. ❑Yes Al ❑Yes ❑No ❑Unknown 7935 Stonecreek Dr in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown Chanhassen, MN 55317 in.from to _ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNERS NAME/COMPANY NAME SCREEN/OPEN HOLE Well owner's mailing address if different than property owner's address indicated above Screen from • to -760ft. Open Hole from to ft. OBSTRUCTIONS %Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction Type of Obstructions(Describe) /4.4.4)Lf1 /2 Pf e Puii Q GEOLOGICAL MATERIAL COLOR FORMATION 7`HARDNESS OR FROM TO Obstructions removed? 1❑I Yes ❑No Describe / PUMP If not k own,indicate estimated formation log from nearby well or boring.cl !2 p / Type SUV 1 tj(nifol go gRemoved ❑Not Preset ❑Other METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: RIVo Annular Space Exists ❑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 of cement=94 lbs.,one bag of bentonite=50 lbs.) I Grouting MaterialA,47 mMAfr from S to 7d, ft. yards 7 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 No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION Mote: Address was changed after This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report permits were taken out. is true to the best of my knowledge. Don Stodola Well Drilling Co,. Inc. 1691 chanbe 4199 North Shore Dr, Orono to Licensee Business NameLicense or Registration No. 1565 Fairview Cottage Lane, Orono Coed el resentative Signature - Certified Rep.No. Date P 9 P -,..t125-4-‘42.-41W--`--# LOCAL COPY 11 312 0 2 Name of Person Sealing Well or Bo ng HE-01434-13 IC#140-0423 5n2R i