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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 119970 <br /> WELL OR BORING LOCATION Sealin <br /> County Name — WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name •Township No. Range No. Section No. Fraction(sm.-)i.lg.) Date Sealed Date Well or Boring Constructed <br /> Oram 118 ' ''.. /5' JoA-. -: 57 <br /> Numerical Street Address or Fire Number and Cityitof Wellllor Boring Location y^: / 1 <br /> 2U Orono C`ecn a ci RC1.N.t rr Ci nC� Mn ,Depth Before Sealing_ (° ft. Original Depth �-�^' ft. <br /> Show exact location of well or boring 5 C-,3,1 Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". location, showing property Ag Single Aquifer p Multiaquifer <br /> lines,roads,and bu4 ngs. y� <br /> N WELL/BORING )(Measured ❑ Estimated <br /> r---r--- <br /> \ \;\ . <br /> % ater Supply Well ❑Monit.Well �\ ❑ Env.Bore Hole ❑Other 1 / ft. elow ❑ above land surface <br /> yyr--- ----n nCASINGTYPE(S) <br /> r -- -1 nSSteel ❑ Plastic ❑Tile ❑ Other <br /> I umile iCASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> 11 r <br /> pt, r mile h in.from U to 76. ft. ❑ Yes No ❑ Yes ❑ No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑ No ❑ Unknown <br /> Jim Murphy 1 <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown IF.. <br /> 30 Orono Orches r4s�N HOLE <br /> Oronc�,�iN53�31 —y r , <br /> /1 <br /> Screen from /�r' to P1 Q ft. Open Hole from to ft. <br /> 476-4a84 OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME <br /> %Obstruction ❑ Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill -.•L N/t//' /J,,../42G- ¢ JF/ <br /> Obstruction/Debris/Fill removed? ,XYes 0 No <br /> PUMP <br /> Type .J/ l PUfi/y)f3 <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 /> o -` t 1 .X"No Annular Space Exits <br /> ❑ Annular space grouted with tremie pipe <br /> r <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(S) <br /> / <br /> Grouting Material 1Cf4117-C 1r7,44(re f'..9to G ft. yards �/ 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 UNSEALED WELLS AND BORINGS ,,��// <br /> Other unsealed well or boring on property? ❑ Yes )) (No <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> I <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. 2717'z <br /> Contractor Business Name /../,--," , License or Registration No. <br /> •,,,tut rizer Representative Signature Date <br /> ./t .4Iv'tiA4-1,,ti <br /> LOCAL COPY H 119970 Name of Person Sealing Well or Boring <br /> HE-01434-02 10/95R <br />