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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring HSlin2170 <br /> L` <br /> County Name <br /> WELL AND BORING SEALING RECORD Minneso aoUnique Well No. �j <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> P (Lame blank n-kn-n) <br /> Township e Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> l4 6 t/--Orono 11 a 172 1A % D 07 <br /> GPS Latitude degrees minutes seconds Depth Before Sealing 5111�& ft. Original Depth __ft. <br /> LOCATION: Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 3505 Wayzata Blvd., Orono WELL/BORING —PeMeasured ❑Estimated Date Measured <br /> Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring "' <br /> in section grid with"X" location,showin property ❑Env.Bore Hole ❑Other _! ft. below El above land surface <br /> N r 1 lines,r ds,a uildin CASINGTYPE(S) <br /> --'--- --i-----`-----'-- tom✓ �-✓ <br /> �T I�wSteal ❑Plastic ❑Tile F]Other <br /> \\\ :LjD' <br /> WELLHEAD COMPLETION <br /> WET ❑ �,I <br /> Outside: Well House ❑At Grade Inside: Basement Offset <br /> r /h Mile F-1Pitless Adapter/Unit E]Buried ❑Well Pit <br /> uried <br /> B <br /> B <br /> S ❑Well Pit ❑Other <br /> 1 Mile ❑Other <br /> 7M 7 RR RTA 185410 <br /> ME <br /> f <br /> 141 <br /> PROPERTY OWNER'S NAME/COMPANY ACASING(S) <br /> Dia eteir Depth r Set in oversize hole? Annular space initially grouted? <br /> roperty owners mailing address if different than well location address indicated above in.from to + ft. LlI�Yes No Ll Yes ❑No ❑Unknown <br /> Carl Bolander & Sons Company in.from to ft. E]Yes ,❑No ❑Yes ❑No ❑Unknown <br /> 251 Slarkey St <br /> St Pau M 5510+ in.from to ft. ❑Yes [-]No El Yes [:]No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> f <br /> Well owner's mailing address if different than property owner's address indicated above Screen from t0._� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL I COLOR HARDNESS OR <br /> FORMATION FROM TO Obstructions removed? Kes ❑No Describe <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. p <br /> i Type Ile u M 17 <br /> 1\r• LyidvRemoved ❑Not Pr sent ❑Other <br /> 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 Material/�/�6/if 4� ���irrom /,o_ toi ft yards--/Z 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 Wo 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 /> Dori Stallb2a %11 Drilling Co.. Inc, 16% <br /> Contractor Business Name License or Registration No. <br /> erti red Pepresentative Signal Certified Rep.No. Date <br /> 21705 <br /> LOCAL COPY �"� <br /> Name of Person Sealing Well or Boring <br /> HE-01434-09 IC#140-0423 sosR <br />