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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 20650 <br /> County Name Sealing <br /> No. 1 <br /> WELL AND BORING SEALING RECORD Minnesota <br /> Minnesota Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank it nol known) <br /> Township Name Township No. Range No. Section No. Fraction Ism�Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 21 .23-003 /7 <br /> GPS Latitude degrees minutes seconds Sr� <br /> LOCATION: Depth Before Sealing "-' ft. Original Depth V ft. <br /> Longitude degrees minutes seconds p IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> 2702 Halters Port Lane, 'Orono W'E!/JBORING Measured ❑ Estimated <br /> 7(Water Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring 757 <br /> in section grid with"X' location,showing property E] Env.Bore Hole E]Other ft. below E]above land surface <br /> N �_ ,} lines,roads,and buildings. CASING TYPE(S) <br /> �V\\' XSteel ❑Plastic ❑Tile ❑Other <br /> W --�- - <br /> -------------- E WELLHEAD COMPLETION <br /> , Outside: Well House Inside: E]Basement Offset <br /> l4mtb - (itess Adapter/Unit E]Well Pit <br /> 1 \ ❑Well Pit ❑Buried <br /> S �1 <br /> r""t° ` - ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Andrew McDe rmo952-471-9898 Diame �� Depth 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 �-R. ❑Yes XNo E]Yes ❑No [j 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 r r <br /> Well owner s mailing address if different than property owner's address indicated above Screen from ,.L to—35,5 ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) J; A.162 /27- /eU/�� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? es ❑ No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring <br /> . � Type 5 c)(�; 6)j?`]n <br /> Removed ❑ Not Present ❑ Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �tNo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> J� 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 /> i <br /> Grouting Material Ale/1 T ft. yards _2�L 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 X <br /> No 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 ame License or Registration No. <br /> A hori d Representative Signature Date <br /> OCAL COPY H 2 0 6 5 0 1 ✓ <br /> Name of Person Sealing Well or Baring �' <br />