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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 352211 <br /> WELL AND BORING SEALING RECORD Sealing No. <br /> County Name Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin <br /> (Leave nark n m known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 -07 Sr' SE SS /2/y/!l? <br /> GPS LOCATION-decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 92 Latitude Longitude <br /> ft. Original Depth ft. <br /> AQUIFERS) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Mukiaquifer �rv►�A,��/ <br /> 't(77J,�,3'!ghwood ' C�+sl1. WELL/BORING xMeasured Date Measured S.n r f��/7 T ❑Estimated <br /> J ��4 Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other f(/l",i4.Ja ft. gbelow ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> A, • <br /> J� y <br /> t�Steel ❑Plastic ❑Tile ❑Other <br /> WELLHEAD COMPLETION <br /> w , : ; , ET � <br /> __;__ _r_ <br /> _ l i. .f___ ! Outside: ❑Pities Adapter/Unit ❑At Grade Inside: XBasement Offset <br /> ; Mile Well Pit ❑Buried ❑Well House <br /> --;-- i T RECEIVED <br /> EIVED <br /> s .1 ❑Other ❑Well Pit G <br /> ) 1 Mlle--1 9 ❑Buried <br /> Il ❑Other JAN 1 02018 <br /> PROPERTY OWNER'S NAME/COMPANYCONAME - CASING(S) <br /> Scott �.now Diameter Depth , Set in oversize hole? Annular yyy���aaa C'7W t' r <br /> Property owner's mailing address f different than well location address indicated above NO <br /> Z r�in.from 6 to38 ft. ❑Yes KNo ❑Yes IC No Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> 3Well owner's mailing address if different than property owner's address indicated above Screen from ,V1140 to L ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill [ to Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FORMATION FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> If not nown,indicate estimated formation log from nearby well or boring. PUMP <br /> L/ 2 XNot Present ❑Present,Removed Prior to Sealing ❑Other <br /> Type <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> >(No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> Casing 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 TN# <br /> GROUTING MATERIAL(S) (One bag of cement= lbs.,one bag of bentonite=50 lbs.) <br /> ' <br /> Grouting Material 6l/4Q S tJ7 �from,_t,gr___ to 44/2ft. yards I bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS e <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes I�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 /> Don Stodola Well Drilling Co,. Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> : ✓ / 7 <br /> nese alive ature Certified Rep.No. Date <br /> E <br /> LOCAL COPY H 352211 <br /> Name of Person Sealing Well or Boring, <br /> HE-01434-15 ID#53159 <br /> 6/i6R <br />