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._ _ _. _ _ '"� WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H — WELL AND BORING SEALING RECORD Sealing No. County Name Minnesota Unique Well No. �Tltle ln Minnesota Statutes, Chapter 103f or W-series No. b (Leave blank I�not known) Township Name Township No. Range No. Section No. Fraction(sm.—�Ig.) Date Sealed Date Well or Boring Constructed � Orono 117 23 23 '' '' '' 1Q-27-O6 Latitude degrees____. minutes seconds 2 �] �, GPS Depth Before Sealing 37 ft. Original Depih_�7� ft. LOCATION: Longitude degrees__ minutes seconds A�UIFER(S) STATIC WATER LEVEL - Numerical Street Address or Fire Number and Ciry of Well or Boring Location �Single Aquifer ❑Multiaquifer ry� WELLIBORING Measured ❑Estimated Date Measured lw Bj'g Isla�� Or�� ;Water-Su I Well pp y ❑Monit.Well Show exact location of well or boring Sketch map of well or boring (� . in section grid with"X" bca' , owing property �..J Env.Bore Hole ❑Other JO k. �below ��=�above land surface li ,roads,a buddings. N �. CASING TYPE(S) a ,.>E _ Steel [_Plastic ❑Tile '. :Other_ _ ___ � � � � �fY --'--- --�--- ---`-----+-- WELLHEAD COMPLETION W � � � � E-r- / __;___ __;___ ___;__ ___r__ I utsid �(�Well House ��At Grade Inside: j-1 Basement Oftset � O ' e: ; � , , , 'h Miie f��- i�Pitless Adapter/Unit ��Buried ^!Well Pit --,- � � _ 1 �� , I--- --f i- - j Buried ' ' S ' ' � L�Well Pit (_]Other �--1 Mile� ��3 T� ❑Oth2f "](�.. PROPERTY OWNER'S NAME/COMPA NAME CASING(S) C�t of Orono Diameter Depth Set in oversize hole? Annular space initially grouted? Properry owners mailing address if dittere than well location ad ess indicated above �in.from�_ to__�_�Q_ .. ft. �Yes ❑No ❑Yes j_;No �]UnknoWn P•�• �$ 66 " in.fromL7o to ��O ft ❑Yes ❑No ❑Yes . ❑No ;r�Unknown Crystal Ba.y, M[�TT 55323 - in.from_, to ft. ❑Yes '..]No �]Yes ❑No (`]Unknown� WELL OWNER'S NAME/COMPANY ME SCREEWOPEN HOLE �" Well owner's mailing address if diRerent than properry ownePs address indicated above SCreen from_____to ft. Open Hole from ��^'____to�� ft. " OBSTRUCTIONS . Rods/Drop Pipe ❑Check Valve(s) [_-��Debris C Fill �j No Obstruction i Type of Obstructions(Describe) iLl�2er pi� & p�p _ GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. drift O no Type ' Removed ❑Not Present ❑Other METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: �I Np Annular Space Exists ��nular Space Grgyitg�ith Tremie Pipe �Casing Perforation/Removal LF in.from to 1`j fl. ��Perforated ❑Removed sandstone (jor n) 43 76 - — --- in.from_ _ _ to ft. ❑Perforated [_]Removed Type of Perforator AYdralic 'J'�Other_ GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) Grouting Material neat C�Qt _ from_ � to__�g./L ft.__ yards 17G __ 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?__ Geology taken f ran Mpls/St Paul LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report area book 1938, pg 158 record 66 is true ro the best of my knowledge. Mpls Suburban RR Big island Park � Stodola Well Drilling Co., Inc. 1691 Iake Mirinetonka _ _-- -_ - — - -- — Contractor Business Name � License or Registration No. 12-18-06 epresentative ignature Certil,%ed Rep.No. Date IMPORTANT-FILE WITH PROPERTY H 2 4 7 5 21 J� �jC� --__ _ __-- - PAPERS-WELL OWNER COPY Name of Person Sealing Well or Boring � � HE-01434-09 IC#140-0423 siosa