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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 5 4 9 5 4 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnle9oNa Unique Well No. <br /> Hennepin Minnesota Statutes, Chapter 1031 or W-series No. <br /> (Leave blank i�not knownJ <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+IgJ Date Sealed Date Well or Boring Constructed � <br /> Orono 117 3 2 24 YO '� '� �v(��/' OC� <br /> �} . <br /> GPS Latitude degrees minutes seconds Depth Before Sealing 7� ft. Original Depth ft. <br /> LOCATION: Longitude_._ degrees__._ minutes__ _ seconds <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ���Mf AQ�J <br /> 3/�p +� Measured Estimated Date Measured ��� �i�' <br /> C1C�� �C� Point Rd, �r� 55,7'1 Y✓ELUBORING / ❑ --- <br /> , I Water-Supply Well �i Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring - <br /> in section grid with"X" /"�'• locati showing pro rt I_i Env.Bore Hole ❑Other �� h. �below ❑above land surface <br /> � 'ine ,�d�,an3buil� <br /> N � „�Y �s�h. J�. CASING TYPE(S) <br /> ----------- --- ----- -- . _____ . ���Steel ❑Piastic ❑Tile ❑Other <br /> � WELLHEAD COMPLETION <br /> W E �\ <br /> ° � � � � � Outside: !]Well House i_i/+t Grade Inside: ❑Basement Offset <br /> , --�--- ---�----�-- ---�- <br /> iie ��Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> ' --�--- --�-----�- ---�- ��. <br /> - ❑Buried <br /> �Well Pit <br /> S ❑Other <br /> �t Mile� []OthOf <br /> �OPERT�OWNER'S NAM COMPA �Ej CASING(S) <br /> � 7NtZ�r�t� ��� '*����2 Diameter r Dep � Set in oversire hole? Annular space initially grouted? � <br /> Property owner's mailing address if different than well location address indicatetl above �� /_ �,( <br /> - �in.fromi� to �� ft. ❑Yes �/]Wo ❑Yes ❑No ❑Unknown <br /> 5 <br /> { in.from to ft. ❑Yes ❑No ❑Yes �]No �L]Unknown <br /> � - in.from to ft. Yes <br /> [] ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME � SCREEN/OPEN HOLE / � <br /> r ( <br /> Well owner's mailing address if different ihan property owrer's address indicated above SCfeen(rom�, to�J ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ' Rods/Drop Pipe ❑Check Valve(s) �',Debris ;�Fill ❑No Obstruction �� <br /> Type of Obstructions(Describe)���C.r'J �G'J 3 � �"������/\J <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed7�I Yes ❑No Describe <br /> FORMATION -- <br /> PUMP <br /> If not nown,indicate estimated formation log from nearby well or boring. �rn�,v� /�u�� <br /> Type J���� /� <br /> `-�"' ��J (�Removed ❑Not Present [J Other ___ <br /> METHOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �� No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perioration/Removal <br /> in.from _..__._to___ ft. ❑Perforated ❑Removed <br /> in.from to ft. LJ Perforated [',Removed <br /> Type of Perforator _ <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �` A� r ��'' • <br /> GroutingMateriaV"��� C=/�r'�- from � to Z ft. yards� bags <br /> from to ft. _ yards bags <br /> from___ to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? �I Yes�No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> 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 /> Dan Stodola Well Dcil n C ' . _15�1_ <br /> Contractor Busines a /' License or Registration No. <br /> 3 � r' _ / / // //_ <br /> 1. / �+� �J 'GJ <br /> ��. <br /> C ied presentative Signature ,, Certilied Rep.No. Date <br /> = F., 5 4 � �. �'..:�-� .�,,�..,�� �, <br /> LOCAL COPY 2 9�4 —� <br /> Name of Person Sealing Well or Boring <br /> HE-01434-09 IC#140-0423 �� �� s/oea <br />