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f , <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSealH 206581 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota aoUnique Well No. <br /> i # i� Hennepin Minnesota Statutes,Chapter 1031 orraW-series No. <br /> Township Name Township No. Range No. Section No. Fraction(sm-)-Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 2-0020 ��� 0� <br /> GPS Latitude degrees minutes seconds /Z L� <br /> LOCATION: Depth Before Sealing ft. Original Depth 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 /> WELUBORING JyMeasured ❑Estimated <br /> 4753 N Shore Dr _ Orono 55364 YvaterSupply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" to a).on,showing property ❑Env.Bore Hole ❑Other ft. [below ❑above land surface <br /> N f? li roads,a ildings. <br /> ! n' n CASING TYPE(S) <br /> I � i feel ❑Plastic ❑Tile E]Other <br /> W E }{' WELLHEAD COMPLETION <br /> � Outside: E]Well House Inside: E]Basement Offset <br /> f4 mik [�fitess Adapter/Unit E]Well Pit <br /> i i - I i t <br /> 1 t t r %% ❑Well Pit ❑Buried <br /> s C y <br /> ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mails dress if different than well location address indicated abov — If—/—,in <br /> n.from_-) to 1,2 ft. ❑Yes XO ❑Yes ❑No E]Unknown <br /> X in.from t0 ft. E]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 /> r � <br /> Well owner's mailing address if different than property owner's address indicated above Screen from /26 to_/2 ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> yods/Drop Pipe ❑Check Valve(s) ❑ Debris <br /> ❑ Fill ❑ No Obstruction n <br /> Type of Obstructions(Describe) _AJ44e=a /_/j�+� 9 4 j"21 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? S El Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP /�,n �` <br /> Type_,50 f\Iu-,m I? <br /> drift Cfiemoved �❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> C9.ldo Annular Space Exists ❑ Annular space grouted with tremie pipe El Casing Perforation/Removal <br /> JJ�� 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 of cement=94 lbs.,one bag of bentonite=50 lbs.) J/� <br /> Grouting Material _ _ mm___6�_to�i4.1.—' yards %[ J 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? XYes o 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 Name License or Registration No. <br /> ljolfor&ed' e resentative Signature - e <br /> LOCAL COPY Fi 206581 <br /> Name of Person Sealing Well or Boring Jim Antonson <br />