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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H <br /> WELL <br /> OR RNa �BORING LOCATION WELL AND BORING SEALING RECORDCe Minling Na Unique Well No. 0 • <br /> 6 1 <br /> Hennepin Minnesota Statutes,chapter 1031 or W-series No. <br /> P (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed 'Date Well or Boring Constructed <br /> Orono 117 23 04 NW NW NW �I,!j -`;, . O <br /> GPS LOCATION-decimal degrees(to four decimal places) • <br /> Depth at Time of Sealing /'L.9 ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL • <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �I�� . <br /> WELL/BORING Measured Date Measured i1'.,,5 - .,J --.,,`-SIJ Estimated <br /> 31115 W t rtetan Rd, .I?man 55356 g Water-Supply Well ❑Env.Well - <br /> SS��yww exact location of well or boring Sketch map of well or boring <br /> invlection grid with"X." loc ion,showing pro•4• Temp.Boring ❑Other (fit✓p ft. �elow ❑above land surface <br /> N 1 04141.-•lin r s,and buil.',-• CASING TYPE(S) <br /> t - <br /> tSteel ❑Plastic ❑Tile ❑Other ' <br /> '--'-'-"-'----"`"--'-"' <br /> WELLHEAD COMPLETION <br /> W y___ �______ E <br /> T Outside:19V I�Pitless Adapter/Unit ❑At Grade Inside: El Basement Offset <br /> 'h Mile ]❑_Well Pit ❑Buried . '❑Well House <br /> •- 1 . <br /> ❑Other El Well Pit <br /> s ❑Buried <br /> I 1 Mile <br /> ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter �\ Depth r Set in oversize hole? Annular space initially grouted? <br /> PROPERTYyOWNER'S NAME/COMPANY NAME - in.from t✓ to ,I/ ft. ❑Yes I(Jo ❑Yes ❑No ❑Unknown. . • <br /> MaL�_ &-Tari— t IW <br /> Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEWOPEN HOLE <br /> WELL OWNER'S NAME/COMPANY NAME Screen from /i q to / 3 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above $Rods/Drop Pipe ❑Check Valve(s) <br /> ❑Debris ❑Fill ❑No Obstruction . <br /> Type of Obstructions(Describe) . -a <br /> 1 <br /> Obstructions removed? 7,Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present [ Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type , <br /> 0 ) 6 3 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> VNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> easing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yes (LINO TN# . <br /> GROUTING MATERIAL(S) ]]'' <br /> c <br /> Grouting Material,1 f -} C) to I. 3 ft. yards /9. <br /> bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes TX No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> Don Stodola Well Drilling Co,. Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> lF <br /> fir ./ / //,/r > C,_.,✓� , <br /> Certified P)eprese�ative Sift ature Certified Rep.N'o.✓ Date <br /> H 3 8 0 6 1 5 \''',--..' sZa.. ..n/Lo <br /> LOCAL COPY Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/198 <br />