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HomeMy WebLinkAboutwell info WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H y 281800 1 WELL AND BORING SEALING RECORD SMinnesota lng oUnique Well No. County Name Minnesota Statutes,Chapter 1031 or W-series No. HerinePin (Leave blank if not known) Township Name Township No. Range No.Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed On so 117 23 09 NE NE NE `-/ A 09 GPSu de es �_ to seconds /Depth Before Sealing 02 ft. Original Depth ft. LOCA _ O IFER(S) STATIC WATER LEVEL Numerical Street reet Address or Fire Number*and City of Well or Boring Location ( Single Aquifer ❑Multiaquifer 1000 Old Crystal Ba Rd S W UBORING Measured ❑Estimated Date Measured 5em� /AY sWater-Supply Well ❑Monit.Well t Show exact location of well o5W17.. Sketch map of well or..'•• in section grid with"X." location ' . . ..erty ❑Env.Bore Hole ❑Other ft. 'below ❑above land surface , oads, nd buildings. N CASING TYPE(S) yIP Xteel ❑Plastic ❑Tile ❑Other ---i------'--------------- 1 �► .................""'""' ‘Wit W HEAD COMPLETION w E1. __ I r ' ___ '- side: ❑Well House ❑At Grade Inside: ❑Basement Offset 'h Mile- itless Adapter/Unit ❑Buried ❑Well Pit 1 ,. ❑Buried '�, ' r ❑Well Pit S ❑Other I-1 Mile- I -_ ‘......+"'"- ❑Other PROPERTY R'' OWNESSyN2AME/COMPANNY NAME CASING(S) Robert Elizabeth Melamed Dianme}[�� 'l m f Depth f Set in oversizersizhole? Annular space initially grouted? Property owner's mailing address if different than well location address indicated above - Y in.from CJ to ft. ❑Yes No 111 Yes El 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 rr���} . Well owner's mailing address if different than property owner's address indicated above Screen from ce f to /V 2 ft. Open Hole from to ft. OBSTRUCTIONS ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris U Fill ) o Obstruction Type of Obstructions(Describe) GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe FORMATION PUMP If not known,indicate estimated formation log from nearby well or boring. ^Y. /► Type '~� 1. / ❑Removed Xlot Present ❑Other i METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: r 'No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ElCasing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed ., Type of Perforator ❑Other GROUTING MATERIAL(S) (One bag of cement=94 lbs.,onebagof bentonite=50 lbs.) Grouting Material V from 0 to ! � ft. yards bags . 104 from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes)(lo 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 to the best of my knowledge. Don Stodola Well Drilling Co,. Inc. 1691 Licensee Business Na License or Registration No.y. 8- y Q l 'fir ifi Representative Signature Certified Rep.No. Date COPY H 281800 — Name of Person Sealing Well or Boring - - HE-01434-11 IC#140-0423 281800 )—w--- Name 2/08R WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MIN AND BORINGG UE NO.WELL County Name WELL AND BORING RECORD 770 0 2 5 Minnesota Statutes,Chapter 1031 lipnropin Township Name Township No. Range No. Section No. Fraction WELUBORING DEPTH(completed) DATE WORK COMPLETED 0rcm 117 23 04 NE NE NE 'i 109 ft. 7-22-09 GPS DRILLING METHOD LOCATION: Latitude degrees minutes - seconds ❑Cable Tool ❑Driven ❑Dug Longitude degrees minutes seconds ❑Auger Rotary ❑Jetted House Number,Street Name,City,and Zip Code of Well Location or Fire Number ❑ IM. Old Crystal Ann' S, Orono 55391 DRILLING FLUID WELL HYDROFRACTURED? ❑Yes �I�lo Show exact location of well/boring in section grid "X."iSketch map of well/boring location. From ft.To ft. � Showing property lines, water N ,.F i �,.� roads,buildings,and direction. USE f-y+f)omestic ❑Monitoring g ❑Heating/Cooling -_______ ______________ F! ❑Noncommunity PWS L Environ.Bore Hole ❑Industry/Commercial �+..._S'1 El Community PWS ❑Irrigation E]Remedial ------ --'------`------`--- \( ❑Elevator "'Dewatering ❑ 4:. TCASING MATERIAL Drive Shoe? ❑Yes [y�ftlo HOLE DIAM. - c. ❑Steel ❑Threaded El Welded --- '/z Mile ' (I,,k __. ..Plastic ❑ s--...., O"' CASING S Diameter Weight Specifications I 1 Mile 1-J 4 in.to 101 ft. 1.9 lbs./ft. a 8_in.to__.. PROPERTY _�OWNER'S INAME/COMPANY NAME m.to ft. lbs./ft. in.to_ . Rehpr,t/Pi izAheth in.to ft. lbs./ft. in.to ft. Property owner's mailing address if different than well location address indicated above. SCREEN OPEN HOLE Make Johnson From ft. To ft. same as Alive Type s_ tea _st Diam. 3W Slot/Gauze o.A Length 49 ♦ 41 Set between t{�L t.and tY ft. FITTINGS Y_NX,14R vtkp STATIC WATERJEWL Ul from a!✓ Measured from 45 ft.c4i0Below ❑Above land surface Date measured 7-22-09 WELL OWNER'S NAME/COMPANY NAME PUMPING LEVEL(below land surface) 98 ft.after 1.5 hrs.pumping 30 g.p.m. Well/boring owner's mailing address if different than property owner's address indicated above. WELLHEAD COMPLETION – ' L� ( Fitless/adapter manufacturer I ;"i-4-., 5 t3.-Jw.r.., Model i Casing Protection ),12 in.above grade ❑At-grade(Environmental Well and Boring ONLY) • GROUTING INFORMATION Well grouted [ Yes ❑No Grout materiels ❑Neat cement bentonite ❑Concrete ❑Other From 0 To_50. 4 ❑Yds. wags GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO From_ To 9,!t. natural [fill❑Bags • MATERIAL gravel, pk From 91 To 109 7 ❑Yds. Lidelags NEAREST KNOWN SOURCE OF CONTAMINATION> gs t oil h��� eft 0 riil feat direction _+� "A''''.4Y4,6� Well disinfected upon completion? [. Yes ❑No J — < Jf-..a.-a) cl*y -_yellow* soft 3 15 PUMP } A ❑Not installed Date installed `7! .75 4 C '7 clay gray mat 15 93 Manufacturer's name Model Number HP 1/4<xltfvolts ?.i) sand brown eft 93 109 ✓`1 Length of drop pipe C'_ T r ft. Capacity g.p.m. Type: ubmersible ❑L.S.Turbine El Reciprocating ❑Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑YesNo VARIANCE r Was a variance granted from the MDH for this well? LlYes Wo TN# WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,if needed. REMARKS,ELEVATION,SOURCE OF DATA,etc. Tion Stodola Well Drilling Co,. Inc. 1691 Licensee Business Name Lic.or Reg.No. C res'entativ Signature Certified Rep.No. Date 1 Chuck ?bore LOCAL COPY 77 0 0 25 Name of Driller IC 140-0020 HE-01205-11(Rev.3/07) r � Laboratory Test Report Engel Water Testing, Inc. 9300 County Rd. 15 * Minnetrista, MN 55359 Phone: (952) 955-1800 Fax: (952)955-1806 Minnesota State Certified Laboratory#027-003-105 *Wisconsin State Certified Laboratory#105-10115 Don Stodola Well Drilling Co., Inc. 3841 North Main Street St. Bonifacius, MN 55375 Water Test Location: Report Issue Date: July 30, 2009 1000 Old Crystal Bay Rd. S. Year: 2009 Orono,MN Date/Time: Sample Collection: 7/22 4pm Date/Time: Sample Recd.in Lab: 7/23 10pm Well Unique Number: 770025 Laboratory Test Number(s): 09-6886 &09-6886A Required when critical to the validity and application of the results Laboratory: Date/Ti3tle ateCl'ime Test Itesult� �x Apprtved Method Test No Sample Prep.....; alysts:; (Mitts) Coliform SM 9223 B 18th ED 09-6886 Bacteria 7/23 lOpm 7/24 lOpm *Positive Colisure© 09-6886 Nitrate 7/24 8am 7/24 8am <1.0 mg/1 Per ISE Method8M 4500- NO3 D 18 ED 09-6886A **Arsenic 7/29 10:30am 0.003 ppm Allowable Limits: > Nitrate Nitrogen,mg/1: Maximum allowable limit is 10.0 mg/I or Less ➢ Coliform Bacteria: Allowable Limit is NEGATIVE > Lead,ppm:Maximum allowable limit is 0.015 ppm or Less > Arsenic,ppm: 0.010 ppm or Less—(0.010 ppm or more exceeds the MDH-recommended health limit for long-term consumption of arsenic in drinking water. Subcontracted test results: ❑ o samples were subcontracted;or s The above test result(s)with"**"designation were produced by Stearns DHEA Laboratories,825 12th St.S.,Sauk Center, MN 56378(MN Cert.No.027-145-378).The subcontracted laboratory maintains MDH certification for the field(s)of testing performed. *Discussion/Notes: These test results are not within the allowable limits for Coliform Bacteria. �J Report authorized by: ///,./- �I"! /'` / / Date: July 30, 2009 Kathryn M. Engel, Laboratory D. ector f The results listed within the report relate only to the samples received on the dates indicated. This report must not be reproduced,except in full,without the written approval from Engel Water Testing,Inc. Created by Engel Water Testing,Inc.October,2008 Page 1 of 1 Twin City Water Clinic Laboratory Test Report Minnesota State Laboratory ID#027-053-119 Wisconsin State Laboratory ID#105-10117 Client: Don Stodola Well Drilling Co, Report Number: 10-02471 Twin City Water Clinic Inc. Sample Collection Date: 12/21/10 617 13th Avenue South Address: 3841 North Main Street Sample Collection Time: 13:30 Hopkins, MN 55343 St.Bonifacius,MN 55375 Sample Receipt Date: 12/22/10 Phone: (952)935-3556 Report Issue Date: 12/23/10 Fax: (952)935-5077 Laboratory Analyte Client ID Parameter Sample Prep Sample Analysis Test Sample ID Date Time Date Time Results Units 10-11748 Coliform Drinking Water 12/22/10 14:11 Absent Nitrate/N Drinking Water mg/I Arsenic Drinking Water pg/I Lead Drinking Water p.g/I 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#770025 1000 old Crystal Bay Rd Orono,MN [Laboratory name;address;MDH Lab ID#]. The subcontracted laboratory maintains MDH Certification for the field(s)of testing performed. Sample Temperature: 15 °C Sample Conditions: Discussion: Notes: Approved methods used in analyzing the samples This Sample meets the listed above have the following reporting levels: Maximum contaminant levels: State of Minnesota, Coliform-<1 cfu/100 ml SM9222B-Coliform, 1 cfu/100 ml Wisconsin and EPA Nitrate Nitrogen 10.0 mg/I 5M4500D-Nitrate Nitrogen, 1.0 mg/I Arsenic, 10.0 µg/I guidelines for safe SM 3003-Arsenic,2.014/ILead,15.0µg/I drinking water for the SM3113-Lead, 2.0 pg/I analytes tested. 7 v �J/ Ili at Sample Collected by: X Client _TCWC Approved By: C Bill Van Arsdale Alan Senechal Laboratory Manager Senior Analyst The results listed in this report apply only to the above listed samples. 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 I 4F.LL L,('.CATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name ipin WELL RECORD 536157 Minnesota Statutes Chapter 1031 Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed ft. Cron° 117 23 09 ,, v. v. 1'06' 12-16-93 Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD ❑ Cable Tool ❑ Driven ❑ Dug 10°0 Old Crystal Bay Road Orono, Mn. ❑ Auger ❑*otary ❑ Jetted SatitIn of well in section grid with"X". chavrerntfir 4. Z Sketch map of well location. ❑ Well Showing property lines, l roads and buildings. DRILLING FLUID j N i --�- -1--1- Qiri WC 41- $t'IItUri1te t i .USE Domestic ❑ Monitoring ❑ Heating/Cooling ❑ Industry/Commercial yy i ; I E Irrigation ❑ Public ._1__-1- -- ^-- T D 0 Test Well 0 Dewatering O Remedial hmi. V CASING Drive Shoe? ❑ Yes ❑ No HOLE DIAM. --t- - - ---r- ❑ teel ❑Xhreaded 0 Welded /mile Q ❑ Plastic ❑ Q� CASING DIAMETER WEIGHT PROPERTY OWNERS NAME4 n.to 104. lbs./ft. lake 'I.,ra. .lCir'Ttes _firs.to :A. in.to ft. lbs./ft. �_/jn,to -ft. Mailing address if different than property address indicated above. in.to ft. lbs./ft. in./ to ft. Bob Melared SCREEN OPEN HOLE 1212 Wayazata Blvd. t-;,,�tMake JO;t,n,,�on from ft.to ft. Way`za tc1� i�l.Cf539 Type '�s'32.I1� 5<i Step" Diam. 4" Slot/Gauze . Length Set between 1€'We ft.and 108 ft. FITTINGS: 4' STATIC WATER LEVEL GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO 40 t MATERIAL ft. ❑flow El above land surface Date measured 12-16-4 t PUMPING LEVEL(below land surface) Clay 90' ft. after hrs.pumping g.p.m. COMPLETIONWELL HEAD Sand 90' 1 U8 f❑fi I ss adapter manufacturer X17 tp4tiltstrModel C Casing Protection ❑I2 in.above grade GROUTING INFORMATION Well grouted? ❑.yes ❑ No Grout Material ❑ Neat cement 0 Bentonite from to .."i- ft. .- ❑ yds. LI .bags from to ft. ❑ yds. ❑ bags from to ft. ❑ yds. ❑ bags NEAREST KNOWN SOURCE OF CONTAMINATIONy-{rr 7c- feet ti�'0�I%, direction �. t4 type Well disinfected upon completion? ❑ Yes 0 No PUMP ❑ Not installed Date installed 2-24-94 4 Manufacturer's name ti/i in F C ari Model number HP i Volts 23(1 Length of drop pipe 4- ft. Capacity 16 g.p.m. Pressure Tank Capacity 1' t..t Wp''.3 vi.,te Type: ❑,submersible C L.S.Turbine 0 Reciprocating 0 Jet ❑ ABANDONED WELLS Does property have any not in use and not sealed well(s)? ❑ Yes ❑)tio WELL CONTRACTOR CERTIFICATION ,J` This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. 1lii S1 1 ff2.. WELL DRL J a NG U ., INC. i.717; Use a second sheet,if needed REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name or Reg.No. -77--- __-- -- 1./-16-9 •r o ed Rep, -nt• 'e ig azure Date F.P. McMahon 12-10-92 Name of Driller Date LOCAL COPY 536157 HE-01205-04(Rev.5/92) t + , = 27.vin City Water Clinic, Inc. 617 13th Ave So • Hopkins,Minnesota 55343 • (612)935-3556 12/18/1993 Stodola Well Drilling 15306 Hwy 7 Minnetonka MN 55345 938-2111 REPORT OF WATER ANALYSIS Lab#: 21731 Our Laboratory reports these analytical results, determined on a sample taken by YOU on 12/16/1993 from the following location: Lake Associates 1000 Old Crystal Bay Rd Orono,Mn Unique.* 536157 Coliform Bacteria <1/100 ml Nitrates Nitrogen 1.13 mg/I The results of these tests indicate that this well is producing water that meets the standards for F.H.A., V.A., or conventional loans. r • \ Water Clinic, Inc. Bill an Brian la Anlyioal laboratory Combing Engines Water Analysis Ragouts Boiler water Chmmi.,Y 1 14 4L TION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. County Name WELL RECORD 5 3 615 6 HeilileP119 Minnesota Statutes Chapter 1031 Township Name Township No. • Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed ft. Orono 117 23 09 V. 1uU' 11-30-93 Numerical Street Address and City of Well Location or Fire Number DRILLING METHOD (`�,,. El Cable Tool 0 Driven 0 Dug 1000 Old CrWed OC ystal Bay N Orono, Ivr.. 0 Auger L (fotary 0 Jetted Sho exact lobation of well in section grid with"X". nn Sketch map of well location. ❑ // v Showing property lines, N roads and buildings./. DRILLING FLUID r t i ,� dr ,USE ❑1�omestic DI Monitoring ❑ Heating/Cooling + - . _ 1- ❑ Industry/Commercial Mite yy i ; I E� ❑ Irrigation ❑ Public __1_-_i_ __ ___ ❑ Test Well OD O Remedial I f mi. O CASING Drive Shoe? ❑ Yes ❑Vo HOLE DIAM. --;- - - ---r- I V ❑steel 0 Breaded ❑ Welded 1-----,„,,,___, O ❑ Plastic ❑ CASING DIAMETER WEIGHT PROPERTY OWNER'S NAME Lake A roc au'j nuc.; 4 in.to 104. lbs./ft. 2 ih,to_;'.ft, in.to ft. lbs./ft. _1ty.to r ft. Mailing address if different than property address indicated above. tti� in.to ft. lbs./ft. in.to ft. 1 212 East Wayzata Blvd SCREEN OPEN HOLE Wayzata t MN. 55391 Make S,Johnson from ft.to ft. '"-,'.yP 3 Type S 11.t lPs step Diam. 41.n Slot/Gauze }�"�(i f� Length 4 r Set between I tl4 ft.and 108 ft. FITTINGS: STATIC WATER LEVEL GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO4li I i MATERIAL ft. ❑$slow ❑ above land surface Date measured 11-30-93 PUMPING LEVEL(below land surface) Clay 0 t 9{)' ft. after hrs.pumping g.p.m. WELL HEAD COMPLETION Sand 90' 1 U ❑Xitless adapter manufacturer WhitPWa t`er Model ❑ Casing Protection ❑12 in.above grade GROUTING INFORMATION Well grouted? ❑ y s 0 No Grout Material ❑ Neat cement ❑ pentonite from ' to t/ ft. 0 yds. 0 (¢egs from to ft. 0 yds. ❑ bags from to ft. 0 yds. D bags NEAREST KNOWN SOURCE OF CONTAMINATION feet direction type Well disinfected upon completion? ❑Xes ❑ No PUMP ❑ Not installed Date installed ��cLr�r, �•.�,..�1-18-94� &2-"94 Manufacturer's name 2RP �dixAfC Model number 63' HP me Vol2 f 210 RECEIVED Length of drop pipe t ft. Capacity g.p.m. Pressure Tank Capacity 120 Gallon Galv. APR 1 4 1994 Type: ❑submersible ❑ L.S.Turbine ❑ Reciprocating ❑ Jet ❑ � ABANDONED WELLS CI■ Y�/OF ORONCI Does property have any not in use and not sealed well(s)? ❑ Yes ❑klo WELL CONTRACTOR CERTIFICATION This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is true to the best of my knowledge. Use a second sheet,it needed DON S WELL DRILLING CO+♦ INC• 27172 REMARKS,ELEVATION,SOURCE OF DATA,etc. Licensee Business Name Lic.or Reg.No. 11-30-94 'utho zed'-presentatiie Signa ur Date F.P. McMahan 11-30-94 Name of Driller Date LOCAL COPY 53615 6 HE-01205-04(Rev.5/92) Twin City Water Clinic, Inc. 617 13th Ave So • Hopkins,Minnesota 55343 • (612)935-3556 12/02/1993 Stodola Well Drilling 15306 Hwy 7 Minnetonka MN 55345 938-2111 REPORT OF WATER ANALYSIS Lab*: 21588 • Our Laboratory reports these analytical results, determined on a sample taken by YOU on 11/30/1993 from the following location: Bob Melamad 1000 Old Crystal Bay Rd Orono,Mn unique.* 536156 Coliform Bacteria <1/100 ml Nitrates Nitrogen <1.0 mg/I The results of these tests indicate that this well is producing water that meets the standards for F.H.A., V.A., or conventional loans. \\ Water Clinic, Inc. Bi • • \ Bria R • ao.lyie.l laboratory Consulting Baginees Water Analysis Reagent. Boiler water Chemicals Minnesota Well and Boring lir WELL OR BORING LOCATION -- MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 75 714 County Name WELL AND BORING SEALING RECORD Minnesota Unique No. Minnesota Statutes.Chapter 1031 or W-series No. Hennepin (Leave blank ii nol knowni Township Name Township No Range No Section No Fraction Ism •Ig) Date Sealed Approximate Date Well Orono1 +� �+�/' c/�� or Boring Constructed 117 21 {9 ii4 L / .71- (47 Numerical Street Address or Fire Number and City of Well or Boring Location e 1 Vacant Lot, Old Crystal Say Rd, Orono Depth Before Sealing ft Original Depth ft Show exact location of well or boring Sketch map of well or boring Static Water Level 'Accurate in section grid with..X.. 4 location.showing property lines. N roads.and buildings. ❑Approximate ^ ingle Aquifer ❑Multiaquiter ? 'ft. below above land surface a - CASING TYPE /� 1�J" W E _ r �t j��V ��. '� Steel ❑Plastic ❑Tile ❑Other maxi ; � 47 ; �J _ Screen from 4 to ft. Open Hole from to ft S HII mile OBSTRUCTION/DEBRIS/FILL Obstruction ❑Debris ❑Fill PROPERTY OWNER'S NAME /� ! )r- ',r hard G. Car x�ntlt�r Trust l [Type of debris/obstruction /-44 i..4-, ' ¢ I 4_ Marling Address if different than property address indicated above. t Obstruction/Debris/Fill removed, es ❑No Attn: Curtis Lee, Trustee PUMP c/oLakewood DEvelopment 1212 Wayzata Blvd _1 A,"" /)C�/77j� emoved ❑Not Present ❑ Other Wayzata, HN 55 91 Att-p Boll MelnmedCASING GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO FORMATION Diameter Depth Set in oversize hole? Annular space initially grouted? If not known.indicate estimated formation log from nearby well or boring. ! ,_y /,. / in.fromC./ to ft. ❑Yeslo ❑Yes ❑No ❑Unknown • I•') in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown in.from to ft. U Yes ❑No ❑Yes ❑No ❑Unknown METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: 14o Annular Space Exists ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of perforator -- ❑Other GROUTING MATERIAL Grouting material �4T 47,4,4i<i(r0lm C 1 to ` Nft. yards 2 bags from _ to ftyards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING from to ft. yards bags from to ftyards bags UNSEALED WELLS AND BORINGS �,/ Other unsealed well or boring on property? ❑Yes KNo 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 to the best of my knowledge. Don Stodola Well Orillinn Co.,Inc. 27172 Contractor Business Name j , License or Registration No r I oe ..ho . '-presentative Signature' Date Name of Person Sealing Well or Boring HE 01434-01