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r- <br /> k <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 144052 <br /> WELL OR BORING LOCATION Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No <br /> (Leave blank if not known) <br /> Township Name Township No. Range No Section No. Fraction Ism.i Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 w ti ka i7 ele <br /> � -,- <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 4040 N Shore Dr, Orono 55391 Depth Before Sealing ft Original Depth 'Z ' <br /> ]? h <br /> Show exact location of well or boring Sketch map of well or boring AOUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X'. location, showing F?Pestsl <br /> In le A uiferlines,roads,and buings g q ❑ Multiaquifer <br /> N I WELL/BORING )(1 Measured ❑ Estimated <br /> -T---T---,----,--- :_...___..._ - • y.Water Supply Well ❑Monit.Well r <br /> ,45 <br /> ( 1 I ❑ Env.Bore Hole ❑Other ft. J4i below ❑ above land surface <br /> W E -'y ‘ CASING TYPE(S) <br /> ' I I <br /> ---r --------i-----{--- t `_,. i )6 Steel ❑ Plastic ❑Tile ❑Other <br /> I I I ne <br /> —1— <br /> _ I <br /> _ _—_ i_ CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted/ <br /> s1 _ ,d <br /> t'nee--- _ in.from to ft. ❑ Yes No ❑ Yes ❑No ❑ Unknown <br /> I r. <br /> PRO2PERTY OWNERS NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Ti <br /> � Flet~, onr`orf 472-4240 Yes No Unknown <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ ❑ ❑ <br /> SCREEN/OPEN HOLE <br /> s <br /> Screen from P to 92 ft. Open Hole from to ft <br /> OBSTRUCTIONS <br /> WELL OWNERS NAME Rods/Drop Pipe p ❑ Check Valve(s) ❑ Debris ❑ Fill 0 No Obstruction <br /> r �'"!h�I j <br /> Weil owner's mailing address A tlifferent than property owner's address indicated /it,�.l above. Type of Obstructions(Describe) f( ui2/ Q 'v/f i <br /> Obstructions removed? , Yes ❑ No Describe <br /> PUMP ������111111 <br /> r Pon",Type f^rF-t ya <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO +Removed ❑ Not Present ❑ Other <br /> FORMATION Jl <br /> M not known,indicate estimated fonnaoon log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XNo Annular Space Exits <br /> ii . _-4) t7 1;=1 <br /> ❑ Annular space grouted with tremie pipe <br /> ' i <br /> ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> infrom to ft ❑ Perforated ❑ Removed <br /> Type of perforator <br /> -- _-_-_ - _ CIOther <br /> GROUTING MATERIAL(S) <br /> i <br /> Grouting Material /4.1..,f47-��/rjtlf/om 0 to 92Z ft. yards ill bags <br /> --- _--- --- -- from to ft yards bags <br /> from to ft. yards bags <br /> from to_ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes>5 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 is <br /> true to the best of my knowledge. <br /> Dpn Stodola Well Drilling Co. , INc. 27172 <br /> Contractor Business Name License or Registration Iro. <br /> (7', <br /> �y / L7jlve signature.- Date <br /> Name of Person Well or Boring <br /> LOCAL(tnPV H 14 4 3 5 2 <br /> HE-01434-03 2/97 R <br />