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Home My WebLink Aboutwell info ` M/NNESOTA UNIQUE WELL WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH AND BOR/NG NO. CountyName WELL AND BORING RECORD �� $ g 1 �tz�pin Minnesota Statutes,Chapter 103/ # Township Name Township No. Range No. Section No. Fraction WELUBORWG DEPTH(completed) DATE WORK COMPLETED Ortmc� 11T 23 09 �F. N�T S�i,� f;j " c}i6..ZQ � GPS DRILLING METHOD LOCATION: Latitude degrees minutes seconds _ Longitude degrees minutes seconds ��'�Cable Tool '�Driven �Dug ❑Auger �Rotary ..;Jetted House Number,Sheet Name,City,and Zip Code of Well Location or Fire Number ��, 3115 Nor�h Stxi � T� DRILLING FLUID WELL HYDROFRACTURED? I I Yes �'No Show exact location of well/boring in section grid with"X:' Sketch map of well/boring location. ��"�,rVliit� From ft.To_ ft. . f Show' roperty lines, — - / -� /roads,buil gs, d direction. USE � :, N �./ y., ��,,�.__ -�j� . '�f Domestic J Monitoring ��_j Heating/Cooling I I � ,_,�,L�.�;�.. '- �.�� : __,_ ___ __� _ ___._ �� -�Noncommunity PWS _��Environ.Bore Hole [l;Industry/Commercial ��]Communiry PWS �. _Irrigation []Remedial I I � ; �\y . . . --'--- --i--- --F'----''- �..� ', w ; ; ; ; e T �V CASING M I St elALr , �,Threaded 9�Yes �'No HOLE DIAM. "- , , I Drive Shoe? --�--- --'--- --F-- ' --- -- ' �,��,Welded � , , , , /Mlle r, , , , , � � , lastic R --�-----T----�----:' _ CASING S � Diameter Weight Specifications i � �R in.to�_ft. ��Ibs./ft. _�_��_�t. t Mile PROPERTY OWNER'S NAME/COMPANY NAME in.to ft. Ibs./ft �in.to�',ft. p� p in.to ft. Ibs./ft. in.to ft. qCCC YO � OPEN HOLE ��- Property owner's mailing address if different than well location address indicated above. SCREEN ____ � 4 L,, -- :. �� Make �1QiH}�� -_- _._.__ From __._ft. To R �, TYPe sg�inle�r� sti Diam. Slot/Gauze_�oi� _ ___ Length_�_� .z t_� ��—a f Set between ft.and___ ft. FITTINGS_ STATIC WATER LEVEL �� Measured(rom `�� ft. -Below ❑Above land surface Date measured �1 V*'�Q WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) �� ft.after ��J hrs.pumping �U g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION '�Pitless/adapter manufacturer �hit�ater Model I Casing Protection �-12 in.above grade I At-grade(Environmental Well and Boring ONLY) GROUTI Gfy INFOR�MA�IO�N� No � �O � Well�f� L �, Gvo�YP�i,l�.g7 N�11c1r�ntltthBentonit�gConcrete [�Other l.��L 2 1111 ,i�J LfJ �* r'��To�ft. � ',��Yds. f�Bags 1 ,y{, HARDNESS OF j' From_ To R ��Yds. (J Bags GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO From To ft. �1��.Yds. �� '��Bags L NEAREST KNOWN SOURCE OF CONTAMINATION '�wt u�� v ��t`— __feet � ��-� direction �- � - ��rype �f *p �/� Well disinfected upon completion? �.Yes 'J No -� - � �,-- �- � '�� y �OA� LCS *,7V PUMP �� r� J Not installed Date installed ��'i+LO �s_ sOf t 6�T 70 , , , Manufacturer's name ,�- , � �r� ��t �O Q� Model Number HP � Volts C?"'"'� O �r Length of drop pipe p� ft. Capacity g.p.m. Type: Submersible ❑LS.Turbine ❑Reciprocating � �Jet .__ �.' ABA ONED WELLS Does property have any not in use and not sealed well(s)? �Yes � .No VARIANCE Was a variance granted from the MDH for this well7 - -Yes No TN# WELL CONTRACTOR CERTIFICATION �� This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The inbrmation contained in this report is true to the best of my knowledge. Use a second sheet,il needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. � SC�OlA �eCI� �TC1111CI� �.cJ�• IE�G• 1 Vy� Licensee Business Name Lic.or Reg.No. / �-"'r- -`��•/ �' t�"'�7�� -� epresentative Signature Certified Rep.No. Date LOCAL CCJPY � � h� � �� C� �� — Name of Driller IC 140-0020 HE-01205-12(Rev.12/OB) � Twin Cit Water Clinic Laborator Test Re ort Minnesota State Laboratory ID#027-053-119 y y p Wisconsin State Laboratory ID#105-10117 Client: Don Stodola Well Drilling Co Report Number: lo-ois5z Twin City Water Clinic Inc. Sample Collection Date: o9/z�/io 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: is:oo Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: o9/za/io Phone: (952)935-3556 Report Issue Date: o9/zs/io Fax: (952)935-5077 Laborator Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 10-09181 Coliform Drinking Water 09/28/10 1328 Absent 10-09181 Nitrate/N Drinking Water 09/28/10 13:52 <1.0 mg/I 10-09181 Arsenic Drinking Water 09/28/10 8:50 09/29/30 12:37 3.87 µg/I Lead Drinking Water µb/� Drinking Water Drinking Water Drinking Water X No samples were subcontracted;or the above test result(s) Sample Conditions/Discussion/Notes: with'**'designation were produced by a subcontracted laboratory. Sample Location-Well#776881 3115 North Shore Drive Orono,MN [Laboratory name;address;MDH Lab ID#]. The subcontracted laboratory maintains MDH Certification for the field(s)of testing performed. Sample Temperature: 13 °C Sample Conditions: Discussion: Notes: Approved methods used in analyzing the samples This 5ample meets the listed above have the following reporting levels: Maximum contaminant levels: State of Minnesota, Coliform-<1 cfu/100 ml Wistonsin and EPA SM92226-Coliform, 1 cfu/100 ml Nitrate Nitrogen 10.0 mg/I SM4500D-Nitrate Nitrogen, 1.0 mg/I qrsenic,10.0 µg/I guidelines fior safe SM 3003-Arsenic, 2.0µg/I Lead,15.0µg/I drinking water for the SM3113-Lead, 2.0µg/I analytes tested. �^ ,�/ �� , Sample Collected by: X Client _TCWC Approved By: ,;` �v� Bill Van Arsdale Alan Senechal Laboratory Manager Senior Analyst The results listed in this report apply only to the above lis�ed sam�les.All routine quality assurance procedures were followed, unless otherwise noted. This analytical report must be reported in its entirety. All methods are certified by the Minnesota Department of Health, unless otherwise noted. TCWD Rev 1.2 Page 1 of 1 WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring t„� ^� {� WELL AND BORING SEALING RECORD MennlesoNa Unique Well No. �" ��`� "�� CpE�nty Name' - - Minnesota Statutes,Chapter f031 or W-series No. � ��;;/,;j Ner�ne ia «aa�a e�a�k,,�o��,ow�, Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed � f?cono 117 23 09 S� NW SW 5'€ p % - ! 'i � � GPS Latitude degrees minutes seconds Depth Before Sealing �� ft. Original Depth '1� ft. LOCATION: Longitude degrees minutes seconds A UIFER(S) STATIC WATER LEVEL �r Numerical Street Address or Fire Number and Ciry of Well or Boring Location ��Single Aquifer ',]Multiaquifer t�,n WELL/BORING y�Measured ❑Estimated Date Measured.'"`�#,/n� l Yt� Water-Supply Well [�Monit.Well � Show exact location of well or boring Sketch map of well or boring i Env.Bore Hole ❑Other � � [�above land surface in section grid with"X." / location,,showing pr erty G �ft. beiow N /� � �nes,road�,a;d bwldi s. , CASING TYPE(S) 1�/ 4.fi��(.•_ ��,� F. ,: --'--- --'-- --`----'- ' I�Steel I�Plastic �Tile ❑Other ' --'--- --�--- ---`-- '--`-- �� WELLHEAD COMPLETION = W ; : ; ; ET �� i _ :�� Outside: �]Well House �At Grade Inside: ❑Basement Offset � 'h M'ie �Pitless Adapter/Unit ❑Buried �]Well Pit --.-- --;-- ---------=-- 1 ❑Buried ' S ' - [_]Well Pit ❑Other �1 Mile� ❑Other PRbO�PERTY OW�1NER'S NAME/COMPANY NAME CASING(S) DCt t YD' t Diameter � Depth � Set in oversize hole? Annular space initially grouted? Property owner's mailing address if diNerent than well location add�ess indicated above �� -, �in.from� to��ft. �Yes �No ❑Yes ❑No ❑Unknown in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. �]Yes ❑No ❑Yes ❑No ❑Unknown WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE f � Well owner's mailing address if different than propeRy owner's address indicated above Scfeen from��to��,__ft. Open Hole ffom to ft. OBSTRUCTIONS ❑Rods/Drop Pipe �]Check Valve(s) ❑Debris ❑Fill �No Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR pROM TO Obstructions removed? ❑Yes ❑No Describe FOHMATION PUMP If not known,indicate estimated formation log from nearby well or boring. Type_ �""� J � � ❑Removed �ot Present ❑Other / s METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: No Annular Space Exists �]Annular Space Grouted with Tremie Pipe I.�Casing Perforation/Removal in.from to ft ❑Perforated ❑Removed in.from to R [j Perforated ❑Removed Type of Perforator r- ❑Other GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite-50 Ibs.) r Grouting Material/�/.�% ('��,�JT from U to� ft. yards�� bags �rom to R. yards bags _.__ from to R. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIfFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes �� No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is true ta the best of my knowledge. Dc� Stodola W�12 Drfllin� Co., Inc. 1b91 ` Licensee Business Name License or Registration No. - - y� � � �J e ed epresentative Signature Certified Rep.No. Date LOCAC.c:OPY � ��0�� i�� J�c7�.�J Name ol Person Sealing Well or Boring HE-01434-12 IC#140-0423 J siosR � . � , � Minnesota Department of Health 121 East Seventh Place P.O. Box 64975 �,•,�;y-;.'�" St. Paul, MN 55164-0975 �� ; ,,1� ��. � i�� January 20, 1998 vi�l0 � '-�r °��, Refer to: License Number 27172 (TN 1614) Ms. Betty Vogt Mr. Robert Waade 375 Leaf Street Robert Waade and Associates Long Lake, Minnesota 55356 1487 Shoreline Drive Wayzata, Minnesota 55391 Mr. Mazk Stodola Don Stodola Well Drilling Company, Inc. 15306 Highway 7 Minnetonka, Minnesota 55345 Dear Ms. Vogt, Mr. Stodola, and Mr. Waade: Subject: Request for a Variance From Minnesota Rules, Chapter 4725 to Construct a Water- Supply Well, Minnesota Unique Well Number 591084, Less Than 50 Feet From the Ordinary High-Water Mazk of Lake Minnetonka at 3115 North Shore Drive, Orono, Hennepin Countv, Minnesota. This letter is in response to your request for a vaziance from Minnesota Rules, Chapter 4725 to construct a water-supply well 40 feet from the ordinary high-water mazk of Lake Minnetonka on the subject property. Minnesota Rules, part 4725.4350 requires that a water- supply well be located at least 50 feet from the ordinary high-water level of a lake. The subject property was inspected by Mr. James Stevens from our metro district office on December 3, 1997. Mr. Stevens has reported that there is no location on the property to :.;,r�struct a w�.:l ir 4onfo.�nariCP. t`Ji�1i ?a�.� Litiii_�i�ia �.3^vi.�.*1C^ u=s*,{:.��s re�uire� by rhir�:.es�ta Rules, Chapter 4725. In accordance with Minnesota Rules, Chapter 4725, your request for a variance is granted. The vaziance is granted because the proposed location for the well, 40 feet from the ordinary high water level of the lake, provides the greatest sepazation distance from the lake while maintaining the minimum separation distances to other sources of contamination including buried sewers. The variance is granted with the following conditions: 1. The well must be located a minimum of 5 feet from the buried gas pipe. If the well will be between 5 and 10 feet of the gas pipe, the well must be mazked with a permanent sign warning of the gas pipe. TDD: (612) 623-5522 (Twin Cities) 1-800-627-3529 (Greater Minnesota) An Equal Opportunity Employer � ;1�. . � Ms. Betty Vogt Mr. Mazk Stodola Mr. Robert Waade Page 2 January 20, 1998 2. The well casing must extend to a depth of at least 50 feet. 3. The annular space between the casing and the bore hole wall, from a minimum depth of 500 feet to the base of the pidess unit, must be filled with neat-cement grout as defined in Minnesota Rules, part 4725.0100 or high solids bentonite grout that is NSF approved and marketed as a well sealani. High solids bentoiufie grout rrYust be r�iiked to the manufacturer's specifications, or must meet the minimum requirements of 15 percent by weight bentonite as specified in Minnesota Rules, Chapter 4725, whichever is heavier. Grout must be inserted through the casing or through a tremie pipe from the bottom up. The annular space below 50 feet must be completely filled with cuttings taken from the � drill hole, or with grout as described above, 4. All buried sewers on the property between 50 and 20 feet of the well must be constructed of cast iron or plastic pipe meeting the material specifications and installation methods described in Minnesota Rules, parts 4715.0530 and 4715.2820. The pipe must be successfully air-tested after installation by a licensed plumber, sewer installer if a plumbing license is not required, or in the presence of a local plumbing or zoning official or Minnesota Department of Health (MDI� representative. The tester must submit written verification that the pipe was successfully tested at a uniform pressure of 5 pounds per square inch for 15 minutes as required by the Minnesota Plumbing Code, rule part 4715.2820. Installation of the sewer must also meet the requirements of the city of Orono. 5. You must contact Mr. Stevens at (612) 215-0830 or Mr. Ron Thompson at (612) 215-0831 at least 24 hours prior to starting well construction so that an inspector may be present during the construction of this well. 6. All other provisions of Minnesota Rules, Chapter 4725, shall be in effect. Alternative measures or conditions attached to a variance have the force of rule and effect of applicable rule. If the party violates the alternative measures or conditions attached to the variance, the party is subject to enforcement actions and penalties provided in the applicable law or rule. This variance is conditioned upon the applicable acceptance of and compliance with the conditions of the variance. Failure by the applicant to comply with the conditions prescribed in the variance will result in the immediate expiration of the variance. � -�* � �. setcy vo� Mr. Mazk Stodola Mr. Robert Waade Page 3 January 20, 1998 If you have any questions or require further information, please contact Mr. Stevens at (612) 215-0830 or Mr. Thompson at (612) 215-0831. Sincerely, I . a Patricia A. Bloomgren, i ector Division of Environmental Health PAB:RDT:fal cc: City of Orono MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIOUE WELL NO. ., ,:�a�ne '-� WELL AND BORING RECORD 5 910 8 4 , ti�3,`::i�'f1177 Minnesota Statures Chapter 1031 �. Township Name Township No. Range No. Section No. Fraction WEL�DEPTH(completed) Date Work Completed n �',_�nc� 117 2� l�� ,. �,. �,. �� ' 1-29-�8 �'� House Number,Street Name,City,and Zip Code of Well Locauon or Flre Number DRILLING METHOD j� � J Northshcre D��.�7� Ur�.��10� � ;,�� n CableTool ❑ Driven ❑ Dug - ❑ Auger �7 Rotary O Jetted Show exact location of well in sedion grid with"X". Sketch map of well location. ❑ __ Showing property lines, -�— N ryI roads and buildings. DRILLING FLUID $��t0n�.t� � i i i � _�♦>.. -i -i- -i- -�- � � ,.!/�� USE � ❑ Monitoring ❑ Heatinq/Cooling � W G Domestic _i_ _�_ _a_ _i_ O j( ❑ Community PWS ❑ Industry/Commercial �� +��:�` i i i i ❑ Irrigation ❑ Noncommunit PWS w E � ❑ Test Well Y ❑ Remedial , � i i � T � - - ❑ Dewatering � _ .r � � � i ,/zIM1e CASING Drive Shoe? ❑ Yes XI No HOLE DIAM. , _i i _L_ _i_ � h ❑ Steel ❑ Threaded ❑ Welded . � _�- � � � �] Plastic ❑ _ __ S Q �-1Mile-� � CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME �i in.ro I� n. SDR—2 1 Ibs./ft. � 1id tbf �'K. Betty Vogt - in.to ft. Ibs./fl. �_��t�.�� Property owner's mailing address if different than well location address indicated above. in.to ft. ____ Ibs./fl. in.to ft. SCFEEN_ OPEN HOLE Make�� n��dn from ft.to fl. Type Stain�ess Steel Diam. L�� SIoVGauze '3/i fl Length �j � Set between �� tt.and__��_tt. FITTINGS: � t STATIC WATER LEVEL s WELL OWNER'S NAME �^� ft.�below ❑ above land surtace Date measured �"29"� � PUM'p7 ING LEVEL(below land surface) 3 Well owner's mailing address if differeM than property owner's address indicated above. ` � __ft. afler � hrs.pumping J U g.p.m. - WELL HEAD COMPLETION �1 Pitlessadaptermanufacturer W�l�..��ldc3�� Model ❑ Casing Protection �,�] 72 in.above grade ❑ At-grade(Environmental Wells and Borings ONLY) GROUTING INFORMvAT��ION Well grouted?�!J Yes ❑ No HARDNESS OF Grout Material f7 Neat cement Benton te ❑ Concrete Hi h Solids Ben�tqnite GEOLOGICAL MATERIALS COLOR MATERIAL FROM TO � � �0, 9 X from � to � ft. � ❑ yds"fl bags from_ to ft. ❑ yds. ❑ bags C�.ci Sand Ca�cl @�. BZc�C�C CJ Q � � from to ft. ❑ yds. ❑ bags NEARES�KN N SOURCE OF CONcTA�MINATION ,/ i�- � feet J UC.� t iY direction � t i � Cla Gr�vel an S 3G 7U � �a,�-ryPe . Well disinfected upon completion. ❑ Yes ❑ Na f� ^� �� .c7t�� .�cin �J �Ei V 2 PUMP ❑ Not installed Date installed L-'t��9� Manutacturer'sname �EC� uc3C}�E� 1 Model number �s" ' HP 1 Volts l�� Length of drop pipe tt. Capaciry �� g.p,m. ��-�- Pressure Tank Capacity. PC��.3 Type: t� Submersible ❑ LS.Turbine ❑ Reciprocating ❑ Jet ❑ _ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes L�IfJo _` , VARIANCE Was a variance granted from the MDH for this well? �Yes ❑ No WELL CONTRACTOR CERTIFICATION Use a second sheet,il needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. REMARKS,ELEVATION,SOURCE OF DATA,eta The information contained in this report is true to the best of my knowledge. DC)N StUDULA WELL DRTLLING CO. , ,TNC. , ` Y _�' i� �i._,� w f Licensee Business Name Lic.or Reg.No ��I r.J \., 'I-' . „ � 3 ��. ��1�I��c��v uthonzed Represent ve Signature Date — _ �'y �;�e Y �r�:: :..: _ F"rea Leib Y 3-1 ts-98 Name ol Driller Date LOCAL COPY 5 910 8 4 „E-0,2a�5,Re�.,,�5> Jwin �itc� UVater ��inic, J`rcc. r 617 13th Ave So • Hopkins, Minnesota 55343 • (612) 935 - 3556 02/02/1998 Stodola Well Drilling 15306 Hwy 7 Minnetonka MN 55345 938-2111 REPORT OF WATER ANALYSIS �: Lab#: 34365 Our Laboratory�eports these analytical results, dete►mined on a sample taken by CLIENT on 01/29/1998 from the following location: . Robert Waade 3115 N. Shore Dr. Orono,Mn Unique 1Mell#591084 Coliform Bacteria <1/100 ml Nitrates Nitrogen <1.0 mg/I The results of these tests indicate that this w�ell is producing water that meets the standards for F.H.A., V.A., or conventional loans. This report is an analysis for coliform and nitrate only and does not inGude analysis of Lead and other contaminants. (Unless as specified by Gient). ater Clinic, Inc. Bill e , ^°.y'��.n�"°ry co�s� w.►a,�y.�xe,g� sou�w.c�cn�.� L�b Certdiaation y 027-033-119 . . . .. �....T�..: _..5. ..•y��..' �. . . WELL OR BORING LOCA710N MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 12 4 8 0 3 �` WELL AND BORING SEALING RECORD Menn�e9oNa Unique No. . County Name HLIIA�QiA Minnesota Statutes,Chapter f031 or W-series No. (Leave Dlank if not known) Township Name Township No. Range No. Section No. Fraction(sm.-►Ig.) Date Sealed Date Well or Boring Constructed Orono 217 `l3 9 ,, ,, , b/13/9'7 � Numerical Street Address or Fire Number and Ciry of Well or Boring Location 3 315 North �ii�r�l Drive Depth Before Sealing 61 ft Original Depth 81 fl. Show exact location of well or boring � Sketch map of well or boring ApUIFER(S) STATIC WATER LEVEL in section grid with"X". f� location, showing property ��ngle Aquifer ❑ Multiaquifer �' lines,roads,and buildings. RECG'•�� N WELUBOR�NG �Aeasured ❑ Estimated `�—'^�---s..P.— ' OQNater Supply Well ❑Monit.Well - - - - -i-- -- -- ,-.._.. � ��.�1. . . �.O '7 ❑ Env.Bore Hole ❑Other ft. �]below ❑ a an ur{�ce1g9 j __f_ _l__ _l__ __l__ W E � CASING TYPE(S) - � i � � � � � � ❑ � ❑ IY �F l)��.�i�� --�- -�-- --�-- --�-- Steel Plastic Tile Other �' W mile --�- -�-- -�-- --�-- � X CASING . Diameter Depth Set in oversize hole? Annualar space initially grouted? � �L� S �J� ,.._—' r mi�e--q„ _...---..._.__._.�_.._.._...._..,... 2 in.from Q to 77 ft. ❑Yes �]No ❑ Ves ❑No ❑ Unknown I � PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑No ❑ Yes ❑No ❑ Unknown . Wa�ber Property owner's mailing address if ditterent than wall location address indicated above. in.from to . ft. ❑ Yes ❑No ❑ YeS ❑No ❑Unknown 3135 North Shore Drive SCREEWOPENHOLE Urono, MN 55391 Screen from 7? to g'1 ft. Open Hole from to fl. 09STRUCTIO WDEBRIS/FILL � WELL OWNER'S NAME �] Obstruction ❑ Debris ❑ Fill ❑ No Obstruction Well owners mailing address if diHerent than property owner's adtlress indicated abova Type of ObslructioNDebns/Fill �u�p � ObslructioNDebris/Fill removad? [�Yes ❑ No PUMP Type 8he3110id i�TElI GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO � Removed ❑ Not Present ❑ Other - FORMATION If not known,indicate estimated tormation log from nearby well o�bonng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: � d r i.f t � $� � No Annular Space Ezits ❑ Annular space grouted with tremie pipe ❑ Casing PeAoration/Removal in.trom to R. ❑ Perforated ❑ Removed in.from to ft. ❑ Perforated ❑ Removed Type of perforator ❑ Other GROUTING MATERIAL(S) GroutingMaterial ��tic3�d from 8� to � ft. yards L bags from to R. yards bags from to ft. yards bags from to ft. yards bags : REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS Other unsealed well or boring on property? ❑ Yes CS No � LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accrordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. R.�S. �tell Drilling '17276 - Contractor Business Name License or Re istratlon�° ��;� �'. _ � ----._ ! 1 I _/ J1 Authonzed Representative SignafurA e�e Jam�s Lea LOCALCOPY H 12 4 8 0 3 Name ol Person Sealing Well or Boring HE-01434-02 10/95R