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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 270245 <br /> WELL QR BORING LOCATION Sealing No. H <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Hennepin (Leave Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 42-0025 2 f �J eJ L O 8 <br /> GPS Latitude degrees minutes seconds Depth Before Sealing 40 ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> $OUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location "Single Aquifer ❑Multiaquifer /� <br /> 1555 orchard, Beach Place, once 55 ELUBORING Measured ❑Estimated Date Measured 5Ivy OAP <br /> ater-Supply Well ❑Monit.Well l t <br /> Show exact location of well or boring Sketch map of well of bo g ~/ <br /> in section grid with"X." location,showing pro e Env.Bore Hole ❑Other ft. Xbelow ❑above land surface <br /> N lines,roads,and builvng. CASING TYPE(S) <br /> % )it Steel ❑Plastic ❑Tile ❑Other <br /> -- -- <br /> r „,,` WELLHEAD COMPLETION <br /> w ET <br /> _I__,_ I � Outside: CI Well House ❑At Grade Inside: ❑Basement Offset <br /> %Miletless Adapter/Unit ❑Buried ❑Well Pit <br /> Pi <br /> Buried <br /> S <br /> ❑Well Pit <br /> 1 t Mile—� ❑Other ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Pat Wysocky Diam , / Depth r Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above (� in.from Q y to `L tt. ❑Yes %No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑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 /> 49'2Q t <br /> Well owner's mailing address if different than property owner's address indicated above Screen from to )� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill XNo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> Ifnotnown,indicate estimated formation log from nearby well or bo/ring. / <br /> (1 i.� V •4 Type <br /> jJt- ❑Removed XrNot Present ❑Other <br /> I' METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> fkiNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑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(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material A/4 Ce/P'C <br /> /,j/ i om © to 96J ft. yards 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? ❑Yes ; to 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 <br /> is true to the best of my knowledge. <br /> Don Stodola Veil Drilling Co., Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> d ative aura Certified Rep.No. Date <br /> LOCAL COPY H ^/7 ^/ 5 Z” : � *~� <br /> i. I 0 2 4 5 Name of Person Sealing Well or Boring <br /> HE-01434-10 IC#140-0423 �.i 5/07R <br />