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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring o. H 206523 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (LeO bt.nk it nod 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 10006 X1J 03 <br /> GPS Latitude degrees minutes seconds F <br /> LOCATION: <br /> Depth Before Sealing l�K ft. Original Depth J ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> WELL/BORING Measured ❑Estimated <br /> 4515 Northshore Dr.• Orono♦ Mn• <br /> Show exact location of well or boring Sketch map of well or boring )(Water Supply Well ❑Monit.Well r <br /> in section grid with"X' Coca bn,showin erty ❑ Env.Bore Hole E]Other15—Z ft. (below ❑above land surface <br /> N � ineroMs e uil gs. <br /> CASING TYPE(S) <br /> " feel ❑ Plastic ❑Tile ❑Other <br /> W- - <br /> ` ' ';" ";-- E WELLHEAD COMPLETION <br /> Outside: ,❑]LLWell House Inside: ❑Basement Offset <br /> kmile Ivi.44 41(1, i L�itess Adapter/Unit ❑Well Pit <br /> 1 ❑Well Pit ❑Buried <br /> r mae <br /> ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASINGS) <br /> Diametek' Depth / Set in oversize hole? Annular space initially grouted? <br /> Property owners mai Ing address it di erent than well Location address indicated above kv <br /> in.from—0 to � / ft. ❑Yes dQvo ❑Yes ❑No ❑Unknown <br /> 4420 Shoreline Drive <br /> Spring Park, MN. 55384 n.from to ft. ❑Yes 0 No ❑Yes F1 No E] Unknown <br /> in.from to ft. ❑Yes ❑ No ❑Yes ❑ No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r / <br /> Welt owner's mailing address if different than property owner's address indicated above Screen from t0 ft. Open Hole from to 1e—s—, ft. <br /> OBSTRUCTIONS <br /> "A Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) _ ZA 444640 Tpe ¢ J�OMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ElNo Describe <br /> FORMATION <br /> If not known.indicate estimated formation log from nearby well or boring PUMP n <br /> Type— f CJ/�'i� <br /> f [!�Iemoved ❑ Not Present ❑Other <br /> 4MEETHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> E)ko Annular Space Exists El Annular space grouted with tremie pipe El Casing Perforation/Removal <br /> ,,`` in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag ofcement=94 lbs.,one bag of bentpnite=50 lbs.) <br /> Grouting Material / G�f�r�// -/"!from 0 to ��� yards � bags <br /> from to ft. yards bags <br /> from to ft yards bags <br /> OTHER WELLS AND BORINGS <br /> 'EMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ 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 is <br /> true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING CO. , INC. 27172 <br /> Contractor Business N e License or Registration No. <br /> A ri R pres ntative Signature Date <br /> 'AL COPY H <br /> 2065231 <br /> Name of Person Sealing Well or Boring <br />