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i � <br /> wELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 0 3 3 3 7 <br /> �'. County Name <br /> WELL AND BORING SEALING RECORD Menn'esoNa Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> He nn e p i n «aa.�e�e�k��,,,o,k�ow�, <br /> ��Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed { <br /> Orono 118 23 26 4f—tt00 Z2, ��� 03 <br /> 5 <br /> , s <br /> � GPS Latitude degrees minutes seconds <br /> - LOCATION: Depth Before Sealing ��� ft. Original Depth ��� ft. <br /> Longitude degrees minutes seconds p �FER(S) STATIC WATER LEVEL <br /> �- Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer y <br /> I125 SpringHill Rd Orono EWBORING I�Wleasured ❑Estimated <br /> � [�q�ater Supply Well ❑Monit.Weil � <br /> ��� Show exact location of well or boring Sketch map of well or boring <br /> = in section grid with"X" c"'� location,showing property ❑ Env.Bore Hole ❑Other _�� ft. �below ❑above land surface <br /> N lines,roa ,and buildir}gq� CASING TYPE(S) <br /> K <br /> Steel ❑Piastic ❑Tile ❑Other <br /> i <br /> W -- - - — - -- -- — E WELLHEAD COMPLETION �� <br /> � <br /> � � � � � Outside: ❑Well House Inside: ❑Basement Offset �' <br /> � <br /> -�-- -�-- -i— -'�-- ;. <br /> Y�m�� ❑ PitessAdapter/Unit �Well Pit <br /> --- -�-- -i-- --�— I ►1 <br /> S ' � - _l� ���� ❑Well Pit ❑Buried <br /> �� o <br /> �rmne� ' � ;: �U� ❑Buried <br /> � PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameter �� Depth � � Set in oversize hole? Annular space initiall;�grouted? <br /> ��� Property owner s mailing address it di er t an well location address indicated above Z�� <br /> � in.from � to ft. ❑Yes �lo ❑Yes ❑ No ❑ Unknown <br /> I8340 Minnetot�ka B1�/� in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown �' <br /> Wayzata, MN 55391 <br /> in.fram to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> ,�� WELLOWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> � f <br /> �r. Well owner�s mailing address if diNereM than property owner's address indicated above Screen from .to ft. Open Hole from�t0 2 �ft. <br /> OBSTRUCTIONS <br /> �Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) �NN�� �T/�L ¢- f�U�y7�-� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 0S ❑ NO D2sCfibO <br /> FORMATION <br /> PUMP <br /> = If not known,indicate estimated forma�ion log from nearby well or boring � � <br /> Type ��� �/el�� <br /> � f`''' � � [�?emoved ❑ Not Present ❑Other <br /> �. r:r . �� ) -�r�1-- <br /> .r:+J . �:r J(�i� 7 METHOD USED TO SEAL ANNULAR SPACE BETWEISN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �Ivo Annular Space Exisis ❑ Annular space grouted with tremie pipe ❑ Casing Pertoration/Removal � <br /> /� <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 Ibs.,one bag of ben�nite=50 Ibs.) <br /> Grouting Material NLlY r �'L���r�L�'"{�pm�to�J�t. yards � v ags <br /> from to ft. yards bags <br /> irom 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 �lo 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 /> � <br /> Don Stodola Well Drilling Ca. , inc. 27172 <br /> Contractor Business Name License or Registration No. <br /> � ��/////� '_�...rf _J � �'" ����� <br /> h �e sentative Signa�i Date <br /> LOCAL COPY H �` "_ }.���.�..4�1^� <br /> 2 O 3 3 3� Name of Person Sealing Well or Boring � <br />