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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 1 <br /> WELL OR BORING LOCATION Sealing No. H 218161 <br /> County Name WELL AND BORING SEALING RECORD <br /> Hennepin Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> heave aaak n flm knownl <br /> Township Name Township No. Range No. Section No. Fraction(sm-*Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118N 23W 35 ''' ''' ''' leo Jit) DV <br /> • <br /> GPS Latitude degrees minutes seconds f <br /> LOCATION: Depth Before Sealing /2(49 ft. Original Depth 126 ft. <br /> Longitude degrees minutes secondsFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer 0 Multiaquifer <br /> 1005 Old Long Lake Rd Orono, mcW�E`WBORING Measured 0 Estimated <br /> (][Water Supply Well ❑Monit.Well r <br /> Show exact location of well or boring Sketch map of well or boring rTTT«�- <br /> in section grid with"X" location,s,•wing property 0 Env.Bore Hole 0 Other ft. below 0 above land surface <br /> lines,r.-' bui <br /> N / ,.. . .,--,. y, * CASING TYPE(S) <br /> 0 Steel t'lastic 0 Tile 0 Other <br /> W - E _—....« WELLHEAD COMPLETION <br /> r _ _ ��( Outside: 0 Well House Inside: 0 Basement Offset I <br /> I f I i kr 111[[[ j pitless Adapter/Unit 0 Well Pit <br /> 116S 0 Well Pit 0 Buried <br /> L' <br /> ~r""I°-+ 0 Buried <br /> l <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Stonehouse Constr. Dia rt.# oDepth/.� { Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above <br /> in.from to/i jj��rr.��. 0 Yes No 0 Yes 0 No 0 Unknown <br /> 420 B. Rice St. <br /> Wayzata, Mn. 55391in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLLEE� t <br /> Well owner's mailing address if different than property owner's address indicated above Screen from ZiZeto rS'ft. Open Hole from to- ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction <br /> Type of Obstructions(Describe). 4 /A1(/ F ¢ /04.417/0 <br /> HARDNESS OR <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO Obstructions removed? Xes 0 No Describe <br /> If noun,indicate estimated formation log from nearby well or boring +�/_PUMP !� (� <br /> '7.5) 0 Irs sPTYpe Vu11 <br /> XRemoved 0 Not Prese 0 Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> Vo Annular Space Exists 0 Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> in.from to ft. 0 Perforated ❑ Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) //!'^ (O,nee bagbaoff�crye+ment=94 lbs.,one bag of bentonite=50 lbs.) /i <br /> Grouting Material y'Ci / rtL�Tj.1 f�r•+�to/2R,f yards ,# bags 9 <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? 0 Yes NrNo 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 /> e erfrettative Sig azure Date <br /> LOCAL COPY H 218161 Name of Person Sealing Well or B 'n <br />