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/ <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring L� A 1007 • y) <br /> WELL OR BORING LOCATION - H 1 f <br /> WELL AND BORING SEALING RECORD Minns ota Unique Well No. C <br /> County Name —,Hennepin Minnesota Statutes,Chapter 1031 oorW-ssve eN es No. <br /> Township Name Township No.• Range No. Section No. Fraction Ism.-e Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 05 23r-0043 ?a AtIS 00 <br /> Numerical Street Address or Fire Number and City of Well or Boring Location r t <br /> 364 W Laky! St, Orono Urf Depth Before Sealing 9 WO ft Original Depth ?WI ft <br /> / <br /> Show exact location of well or boring Sketch map of weler bringpAQUIFER(S) STATIC WATER LEVEL <br /> in section grid with'V. location, erty !ySingle Aquifer ❑ Mulliaquifer <br /> lines,roa ,and build' S. 11YAA 1 <br /> N - WELUBORING ,'Measured ❑ Estimated <br /> I- yWater Supply Well ❑Monit.Well { <br /> ❑ Env.Bore Hole ❑Other Q h. below ❑ above land surface <br /> W---r---r---�-----�--E CASING TYPE(S) <br /> ---i-----1-----i------I--- )(Steel <br /> Steel ❑ Plastic 0 Tile ❑ Other <br /> ) l { { krni <br /> ---1----+---1 t- 1 21.'"). <br /> N 4�r CASING(S) <br /> 1�.j O Diameter /� Depth r Set in oversize hole? Annular space initially grouted? <br /> S .11 Z.11 <br /> �—i mite W from to �� ft. 0 Yes yNo ❑ Yes 0 No ❑ Unknown <br /> PROPERTY OWNER'S NAME c� in.from to ft. ❑ Yes ❑No 0 Yes ❑No ❑ Unknown <br /> Beall ig & Sens <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑No 0 Yes ❑No 0 Unknown <br /> 11441 Cty Rd 3 SCREEN/OPEN HOLE <br /> Hopkins, MN 55343 Screen from 9Z` to % r ft. Open Hole from - to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME Rods/DropPipe <br /> ©a 3 ❑ p 0 Check Valve(s)//��.-- Debris 0 Fill 0 No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstructions(Describe) C.iC� }I 1 <br /> Obstructions removed? Yes 0 No Describe <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed jiirNot Present 1=1Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or bo ng. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> drift 0 )(No Annular Space Exists <br /> 96 ❑Annular space grouted with tremie pipe <br /> O Casing Perforation/Removal <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. ❑ Perforated 0 Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material from 0 to I r ft. yards _Zs_ bags <br /> from to ft. yards bags <br /> from _ to ft. yards bags <br /> from to_ ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS / <br /> Other unsealed and unused well or boring on property? ❑Yes YJ No 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 Ca., Inc. 27172 <br /> Contractor Business Name / - License or Registration No. <br /> ././ -a�/�./�i1 t,; <br /> o .97 . =s=nta"e Sig,rJlf! Date <br /> Jim Antoneon <br /> LOCAL COPY H 170072 Name of Person Sealing Well or Boring <br /> fl <br />