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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring /� <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. 1 H l 6 <br /> County Name Minnesota Unique Well No. — _ <br /> Hennepin Minnesota Statutes. Chapter 1031 or W-series No. <br /> (Leave Sank 4 not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-w Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 09 1L2-000#3,. !0 1 02- . <br /> Numerical Street Address or Fire Number and City of Well or Boring Location i x /" / <br /> 900 Old Crystal Bay yy Rd, S, O ror.�pth Before Sealing �1 6,) tt. Original Depth , r' � ft <br /> Show exact location of well or boring i "J J-etch map of well or botifig /{OyIFER(S) STATIC WATER LEVEL <br /> in section grid with"X" location, showing pfpperty Single Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. ��// <br /> N _ --- WELUBORING L�9.Measured ❑ Estimated <br /> { <br /> ' 1 <br /> r — -1 -1- <br /> --, -' ._ <br /> l - rVater Supply Well ❑MoniL Well <br /> 14F1 1 ❑ Env.Bore Hole ❑Other �,- ft. below El above land surface <br /> W- <br /> r -1 ---- 1 "E 3 y CASING TYPE(S) <br /> ( 1-- -------i----r— 4 y Reel ❑ Plastic ❑Tile ❑ Other <br /> I - $milei -I .......�_.__,._..- <br /> I f CASING(S) <br /> 1 Diameter,,,, Depth f Set in oversize hole? Annular space initially grouted? <br /> r node _ in.from ItO to TX'',ft. ❑ Yes [ 40 ❑ Yes ❑No ❑ Unknown <br /> 1 <br /> PROPERTY OWNER'S NAME infrom to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown <br /> Ken/Julie Riff 952-249-7217 <br /> Property owner's mailing address if different than well location address indicated above . in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> 1 <br /> Screen from .jt' F <br /> , i to UD ft. Open Hole from to _ ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/DropPipe �y�� <br /> ❑ p ❑ Check Valve(s) ❑ Debris ❑ Fill I�lvO Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above Type of Obstructions(Describe) ��\\ <br /> Obstructions removed? ❑Yes ❑ No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed Not Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 'No Annular Space Exists <br /> i ) <br /> ❑Annular space grouted with tremie pipe <br /> ❑Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated Cl Removed <br /> Type of perforator <br /> • t - <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material AJ�44JT(7--":-/./'at-/ ✓ to ea ft. yards .`f bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to— ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yeslo How many? <br /> 1 <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 e License or Registration Pio. <br /> ,e .'1-;''''''' <br /> `'f E' , a/ <br /> A on�� ied Re resentative 9nature Date <br /> C <br /> LOCAL COPY <br /> H Name of Person Sealing Well or Boring <br />