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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 328030 <br /> ® <br /> County Name <br /> WELL AND BORING SEALING RECORD M nnleso aoUnique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin P uea�e aa�a a�m e�ow�t <br /> Township Name Township No. Range No. Section No. Fraction(sm. Ig.) Date Sealed Date Well or Boring Constructed <br /> Oran 117 71 07 Af <br /> GPS LOCATION-decimal degrees(to four decimal places) ^�- r <br /> Depth Before Sealing ..+� ft. Original Depth / -J ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number <br /> and City of Well or Boring Location IQaIngle Aquifer E]Multiaquifer <br /> 4680 North Shore Drill, Orono WELL/BORING Measured ❑Estimated Date Measured <br /> ❑Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring Env.Bore Hole ❑OtherId <br /> ft. elow <br /> n section grid with"X:' location,showing property ❑ ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) 1 VE0 <br /> '- `- V <br /> --'-----;--- -- WELLHEAD COMPLETION de h _ <br /> ❑P ❑T' ❑Other <br /> N o 15 <br /> W EI <br /> y Outside: ❑Well House ❑At Grade Inside: �4asemenLOffset <br /> Mile Pitless Adapter/Unit ❑ urged <br /> We Pit <br /> h ❑ OF ORO <br /> NO <br /> ❑ W <br /> -----T---------- -- I h ❑Buried 0 <br /> 1 i El Well Pit <br /> S �rJF;� Z. E]Other <br /> 1 Mile ElOther <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above / in.from___it' to ft. ❑Yes rvd ❑Yes "O ❑Unknown <br /> 1515 Constawe Blvd -ir.-.--in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Hm Lake, MR 55304 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME S REEWOPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from to Open Open Hole from t0 ft. <br /> OBSTRUCTIONS �r <br /> E]Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill . Obstruction <br /> Type of Obstructions(Describe) ��ii <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> f Type <br /> ❑Removed � of Present ❑Other <br /> MOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exists ❑Annular Space Grouted with Triennia Pipe ❑Casing Perforation/Removal <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 ;04"'Ko TN# <br /> GROUTING MATERIAL(S) �y (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material�Lf:" 17 om to _ 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? ❑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 Drilling Co,. Inc. 1691 <br /> Licensee Business Name - Licen��se or Registration No. <br /> /l r o <br /> esen'tative Signature X Certified Rep.No. Date <br /> LOCAL COPY H � <br /> 3 L 8 0 3® Name of Person Sealing Well or Boring <br /> HE-01434-14 IC#140-0423 5/138 <br />