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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 34 4142
WELL AND BORING SEALING RECORD
County Name Minnesota oUnique Well No.
Minnesota Statutes,Chapter 1031 or W-series No.
� chew blankit not known)
Township Name Township No. Range No. Section No. Fraction(sm.-»Ig.) Date Sealed Date Well or Boring Constructed
or
117 21 06 S St Mi 21 OICT /&
GPS LOCATION—decimal degrees(to four decimal places) �
Depth Before Sealing („i,?f ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer /�/
W LL/BORING XMeasured ❑Estimated Date Measured silo*. MY
4780 North Ana Dr Orono y�A/
1 ater-Supply Well ❑Monit.Well f
Show exact location of well or boring Sketch map of well or boring
in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other 'IS ft. Xbelow ❑above land surface
N lines,roads,and buildings. CASING TYPE(S)
{~ _if ! steel ❑Plastic ❑Tile ❑Other
---i--- --'---F--'------ { ^a t
�1" { WELLHEAD COMPLETION
w r-- E T* r`. _• Outside: ❑Well House ❑At Grade Inside:
❑Basement Offset
; 'h We
❑ ❑Pitless Adapter/Unit Buried ❑Well Pit
S
XWell Pit ❑Buried
I1 Mile--1 ❑Other ❑Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
+:i 1 pn Pnrei Lr Diameter t Depth Al Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above
3
a+�� in.from 'i to ft. ❑Yes No ❑Yes ❑No ❑Unknown
Jl09 D to Ave S in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
St Louis Park, MN 55416
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
r <p- , x r t
ad
Well owner's mailing address if different than pr iia' Ove Screen from to ft. Open Hole from to ft.
_OQSTRUCTIONS
JAN
N 1 8 2017 Rods/Drop Pipe ❑Check Valve(s)Vavee( ❑Debris ❑Fill
i7 ❑No Obstruction
[����{n L
Type of Obstructions(Describe) iA$�-OP S. F -e ,,f( ,
GEOLOGICAL MATERIAL COL'aA' ,I � � TO Obstructions removed? Yes ❑No Describe �•r
If n
A _t known,indicate estimated formation log from nearby well or boring. PUMPd
Removed
❑Not Present 1 ❑Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
7777���� in.from to ft. ❑Perforated ❑Removed
in.from to ft. ❑Perforated ❑Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? ❑YesNo TN#
GROUTING MATERIAL(S) (One bag of cement=lis.,one bag of bentonite=50 lbs.)
Grouting Material dorcagier,.from 7 to 60 ft.
yards iel bags
from to ft. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALINGOthXer unsealed and unused well or boring on property? ❑Yes I�No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION f
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report
is true to the best of my knowledge.
Don Stodola Well Drilling Co,. Inc. 1691
Licensee Bu Name License or Registration No.
J _ f
Az,
:/.�f" ,{.#10;'- #� 0 .try).,�.� '/iG f
,Cfrt
rfi Representative Signature Certified Rep.No. Date
LOCAL COPY 34 4142
Name of Person Sealing Well or.Boring
HE-01434-14 ID#53159 1
5/13R