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WELL OR BORING LOCATION Sealing <br /> DEPARTMENT OF HEALTH Minnesota Well and Boring H 24'4235 <br /> Sealing No. <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin �.wblank Mnot , <br /> Township Name Township No. Range No. Section No. Fraction(sm-ii.Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 05 23-0042 Z,. b EC (:•)S� <br /> GPS Latitude degrees minutes seconds r <br /> LOCATION: Depth Before Sealing 8 9 ft. Original Depth ft. <br /> Longitude degrees minutes seconds AO IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer 0 Multiaquifer <br /> ELL/BORING y Measured ❑Estimated <br /> 365Westlake St, Orono 5 ater Supply Well 0 Monit.Well r <br /> Showexact location of well or boring etcn map of well or boring <br /> in section grid with"X' m.Bore Hole ❑Other 4.,5 ft. Xbelow 0 above land surface <br /> linen ds,-enibuildir gs.. <br /> N err CASING TYPE(S) <br /> '-r--- -�- --'--r-' <br /> Steel IDPlastic ❑Tile 0 Other <br /> W E WELLHEAD COMPLETION <br /> 1 1 1 <br /> a}' Outside: 0 Well House Inside: 0 Basement Offset <br /> 1 I I I <br /> 1mrj ❑Pitless Adapter/Unit ❑Well Pit <br /> 39-A 0 Well Pit 0 Buried <br /> S <br /> -r"'+'- ' \ ..g Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)C <br /> Rel-ort Rrf rksnn 952-475-31n2 Diameter r Depth r Set In oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above 7 J I'S <br /> in.from i 2 O- to ft. 0 Yes >I No 0 Yes ❑No ❑Unknown <br /> 600 Twelve Oaks Center Dr <br /> Ste 654 in.from to ft. 0 Yes 0 No 0 Yes ❑No ❑Unknown <br /> Wayzata, MM 55391 in.from to ft. ❑Yes ❑No ❑Yes ❑No 0 Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> y/�� ,I / <br /> Well owners mailing address if different than property owners address indicated above Screen from `••�_ to _q___ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe 0 Check Valve(s) 0 Debris ❑ Fill X No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 0 Yes 0 No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> drift 0 Type <br /> ❑ Removed ' Not Present 0 Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> yjNo Annular Space Exists 0 Annular space grouted with tremie pipe 0 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 /> M _ /, p <br /> Grouting Material N�rr176479/44-",from Vr to eq 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 !/ • <br /> 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 is <br /> true to the best of my knowledge. <br /> Don Stodola Well Drilling co,. Inc, 27172 <br /> Contractor Business Name ` <br /> fLicense or Registration No. <br /> s /(' 12-15-05 <br /> ."... -'7prese S..t•= •naty.= Date <br /> LOCAL COPY <br /> H 243235Jim Antonson <br /> Name of Person Sealing Well or Boring <br />