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Minnesota Well and Boring u <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 5 9 4 7 0 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. --- .,7 <br /> Minnesota Statutes.Chapter 1031 or W-series No. {p, <br /> Hennepin (Leave blank 4 nor knowni ttt `��� <br /> Township Name Township No. Range No. Section No. Fraction(sm. i Ig.) Date Sealed Approximate Date Well <br /> or Boring Constructed <br /> Orono 117 23 <br /> 09 21 rra` /V _c`P qy <br /> Numerical Street Address or Fire Number and City of Well or Boring Location t Depth Before Sealing /' 1 / <br /> 825 Old Crystal Bay Rd, Orono 55341 //Y ft. Original Depth I( / I ft <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level Accurate <br /> in section grid with"X". location.showing property lines. <br /> roads,and buildings. ❑Approximate <br /> N <br /> r <br /> ingle Aquifer q <br /> ❑Multiaquifer ft ^ below above land surface <br /> i <br /> u ,- CASING TYPE <br /> W E <br /> XSteel ❑Plastic ❑Tile ❑Other <br /> i mile <br /> /G(a / //l / <br /> S Screen from to ft. Open Hole from to ft. <br /> H- I mile-OH OBSTRUCTION/DEBRIS/FILL <br /> %Obstruction ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME <br /> Yeri;an ConstructionJA , A 11 Pr//E 9 9/'01?2 <br /> Type of debris/obstruction ' J <br /> Mailing Address if different than property address indicated above. <br /> Obstruction/Debris/Fill removed? *Yes ❑No <br /> Rt 4, Box 385 PUMP <br /> Isanti, TIN 385 <br /> 55040 444-5453 < 49. /-94(1r7 <br /> Removed ❑Not Present ❑ Other ti <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known.indicate estimated formation log from nearby well or boring. // / /\ f y�_zi- <br /> 1./., in.from e") to ft. ❑Yes )(No ❑Yes ❑No ❑Unknown <br /> drift 0 11C <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> • METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> *No Annular Space Exists <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated 0 Removed <br /> Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material / l'n/ , f.,rom 6 to f ft. yards 2 bags <br /> from to - ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑Yes ❑No <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 /> 9-19-94 <br /> '--A'Lthonzed Representative Signature Date <br /> Jim Antonson <br /> LOCAL COPY H 59470 <br /> Name of Person Sealing Well or Boring <br /> HE-01434-01 <br />