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Minnesota Well and Boring <br />WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No H <br />County Name WELL AND BORING SEALING RECORD Minnesota Unique No 61.547 <br />M dnesota Statutes Chapter 1031 or W -series No <br />Hennepin --- <br />Towosttrp Name iownslvp No Renge No Sectron Nn F r:¢trnn Ism Iq 1 Daft- Sealed Approumale Dale Well <br />Orono 117 23 4 1-5-95 or Boring conslrucled <br />Nunencal Street Address or Fre Number and City of Well or Bor,ng Localwn ' <br />2804 Countryside Dr W Orono 5 5 3 1t1h fielore E..alr,y _._ 148_ 11 Orgnal Depth 152 it <br />Show exact location d wellor boring 11 Sketch ma nor bonny Stahc Water Level W Accurale <br />n action qnd with X �: Cf 1 4eeakbA�how A Ir <br />N roads and thuk,mgs ❑ Approsrmale <br />Aquifer ❑ 190 II R below above land surface <br />W _ r _ _ s _ _f_ I _ CASING TYPE <br />r r ❑ %wo X [ ] T,In ❑ Other <br />rnrr l..unh� . <br />i "k •L� 'rex Removed <br />r S r U„ Screen fromft Open Hole tram to . __— n <br />I map O1 OBSTRUCTIOWDEBRIS/FILL <br />MOPERTY OWNER'S NAME [.] Obslrurhun ❑ Deh-, [_� fit <br />Tony Eiden Co. <br />TYp' of deboS rN)s(runnone <br />Ma.inq Address ifd-ft"daalcd atc <br />4100 Berkshire Lane 0t)%I'Joon Dehns Filll-emaved I L) fes 0 N <br />Plymouth, MN "446 PUMP <br />❑ Removed 2 Nut Pa•sr•r:1 ❑ Oth e <br />VEOLOGICAL MATERIAL <br />I COLOR <br />I HARDNET1pNSS OF <br />I FROM <br />I TO <br />iORMA <br />Uameh•Depth <br />. <br />Set in oversize holo? Annular spate initially gfomed'r <br />M not known formation eslfinelBd Iorfon IOq from nearby well of being <br />Clay <br />black <br />soft <br />0 <br />---- - <br />4 <br />—� <br />4— .n from -_ �_._ to 148 1, <br />El Yes Zl No ❑ 'as ❑ No ❑ Unknd <br />in from __ ,o — It <br />❑ Yes ❑ No Oyes ❑ No ❑ Unkno, <br />Clayn <br />Clay <br />Yello <br />Grp <br />sof <br />sof L <br />18 <br />88 <br />from to _ h <br />❑ Yes 11 No ❑ Yes ❑ No ❑ Unllrtol <br />USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE: <br />Sand/Gravel <br />Tan <br />soft <br />88 <br />148METH <br />Annular Space Exists <br />❑ Annular space grouted with tremre pope <br />_--------- - - <br />❑CasingPedafabonvRemoval <br />- - - <br />m from to <br />n ❑ PerIo .lid U Hemoved <br />in Iron to <br />It [] Pedor,ued f_I Removed <br />REMARKS. SOURCE OF DATA. DIFFICULTIES IN SEALING <br />6154 <br />Type of perforator <br />El ott-o <br />GROUTING MATERIAL <br />Grouhrg ----neat ceftiffidlt0 _. ,�, _148 If _—_-- Yards 7 <br />-- from __ to .._-_ it _ __ vara•. -.. gags <br />UNSEALED WELLS AND BORINGS <br />Other unsealed well or bonny on propeny? ❑ Yes ® N,, <br />LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />This well or boring was sealed to accordance mth Minnesota Rules Chapter e725 The information contained in trus report is <br />true to the bell+ of my knowMdpe <br />Don STodola Well Drilling Co., INc. _27172 <br />Contractor Business Name License or Regrs/r;f n No <br />1-•25-95 <br />ulliorrfed HepreserNafrve•_Syrwfu,a (late - - - <br />- "-- <br />Y <br />Name of Person Seafsg Wee or Soreg <br />