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Minnesota Well and Boring lir <br /> WELL OR BORING LOCATION -- MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 75 714 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Minnesota Statutes.Chapter 1031 or W-series No. <br /> Hennepin (Leave blank ii nol knowni <br /> Township Name Township No Range No Section No Fraction Ism •Ig) Date Sealed Approximate Date Well <br /> Orono1 +� �+�/' c/�� or Boring Constructed <br /> 117 21 {9 ii4 L / .71- (47 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location e 1 <br /> Vacant Lot, Old Crystal Say Rd, Orono <br /> Depth Before Sealing ft Original Depth 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.. 4 location.showing property lines. <br /> N roads.and buildings. ❑Approximate <br /> ^ ingle Aquifer ❑Multiaquiter ? 'ft. below above land surface <br /> a - CASING TYPE /� 1�J" <br /> W E _ r �t <br /> j��V <br /> ��. '� Steel ❑Plastic ❑Tile ❑Other <br /> maxi ; <br /> � 47 <br /> ; <br /> �J _ Screen from 4 to ft. Open Hole from to ft <br /> S <br /> HII mile OBSTRUCTION/DEBRIS/FILL <br /> Obstruction ❑Debris ❑Fill <br /> PROPERTY OWNER'S NAME /� ! )r- <br /> ',r hard G. Car x�ntlt�r Trust l [Type of debris/obstruction /-44 i..4-, ' ¢ I 4_ <br /> Marling Address if different than property address indicated above. t <br /> Obstruction/Debris/Fill removed, es ❑No <br /> Attn: Curtis Lee, Trustee PUMP <br /> c/oLakewood DEvelopment <br /> 1212 Wayzata Blvd _1 A,"" /)C�/77j� <br /> emoved ❑Not Present ❑ Other <br /> Wayzata, HN 55 91 Att-p Boll MelnmedCASING <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. ! <br /> ,_y /,. <br /> / in.fromC./ to ft. ❑Yeslo ❑Yes ❑No ❑Unknown <br /> • <br /> I•') in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. U Yes ❑No ❑Yes ❑No ❑Unknown <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 14o 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 ❑Removed <br /> Type of perforator <br /> -- ❑Other <br /> GROUTING MATERIAL <br /> Grouting material �4T 47,4,4i<i(r0lm C 1 to ` <br /> Nft. yards 2 bags <br /> from _ to ftyards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ftyards bags <br /> UNSEALED WELLS AND BORINGS �,/ <br /> Other unsealed well or boring on property? ❑Yes KNo <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 Orillinn Co.,Inc. 27172 <br /> Contractor Business Name j , License or Registration No <br /> r I <br /> oe <br /> ..ho . '-presentative Signature' Date <br /> Name of Person Sealing Well or Boring <br /> HE 01434-01 <br />