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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSeang No. H <br /> 237125 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Hennepin <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Ltennepin (Leave Wank -k—) <br /> Township Name Township No. Range No. Section No. Fraction(sm-).Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 04 1,".3 .- <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing /� ft. Original Depth 17A[tet ff. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location X Single Aquifer ❑Multiaquifer u <br /> C L WELLBORING XMeasured E] Estimated <br /> 2845 Watertown Rd. Orono 55356 Water Supply Well [j Mond.Well <br /> Show exact location of well or boring Sketch map of well or boring 1112 <br /> ' <br /> in section grid with"X" location,showing property E] Env.Bore Hole [:]Other V ft. Ybelow ❑above land surface <br /> N - j I fts,roads,and buil fngk <br /> CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> -�- -�-- -;-- --,-- WELLHEAD COMPLETION <br /> W E <br /> p Outside: ❑Well House Inside: ❑Basement Offset <br /> limas t+, Pitless Adapter/Unit ❑Well Pit <br /> 2. ❑Well Pit ❑Buried <br /> S <br /> ❑Buried <br /> P P�jRTY O 'S N MP A /fit CASING(S) <br /> lar , 5-1017 Diameter Depth r Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above <br /> 7085 Shady Oak Rd in.from d to 174 ft. ❑Yes XNo ❑Yes ❑No ❑Unknown <br /> Eden Prairie, PET 55344 in.from t0 ft. ❑Yes ❑ No ❑Yes ❑ No ❑Unknown <br /> in.from t0 ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r <br /> Well owner's mailing address if different than property owners address indicated above Screen from t0 ._ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> *X Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) _7_A.J fJ/-A f- JOtJe"42 <br /> GEOLOGICAL MATERIAL TCOLOR HARDNESS OR FROM TO Obstructions removed? Yes ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type �L4� L)A <br /> Removed ❑ Not Present ❑Other <br /> i <br /> i+ METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No 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 Matenal f(,// T C-f!L'1� A.Z from 0 to 1-2p_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 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 /> Dan Stodola Telell Drilling Co, Inc. 27172 <br /> Contractor Business Name License or Registration No. <br /> o d t?Wrese"f9iv6 Signature Date <br /> LOCAL COPY �H237125 Name of Person Sealing Well or Boring <br />