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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring HSeang No. 205675 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 o W-series No. <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 33 41-0012 FF (:53 <br /> GPS Latitude degrees minutes seconds / <br /> LOCATION: Depth Before Sealing /SS / ft. Original Depth /5' / / ft. <br /> Longitude degrees minutes seconds AUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> WE L/BORING $Measured ❑Estimated <br /> 365 Willow Dr N, Orono \ Water Supply Well ❑Monit.Well / <br /> Show exact location of welt or boring /ketch map of well or beri� 2 <br /> in section grid with"X" cation,showing property 0 Env.Bore Hole ❑Other /U_t ft. elow ❑above land surface <br /> N lines,roads,and buildi"9 CASING TYPE(S) <br /> T ` _ ®�� C��' XSteel 0 Plastic ❑Tile ❑Other <br /> ` <br /> W E 0% WELLHEAD COMPLETION <br /> ' T Outside: ❑Well House Inside: ❑Basement Offset <br /> I I I ftmib ❑Pitess Adapter/Unit Nell Pit <br /> S 0 Well Pit ❑Buried <br /> I md. '. �.. ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Ingram Excavating Diame rrr Depth �l / Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above //�� /L. <br /> in.from 0 to /5 ft. ❑Yes [ 14o ❑Yes 0 No 0 Unknown <br /> 18900 Pioneer Trl <br /> Eden Prairie, MN 55144 in.from to ft. ❑Yes ❑No ❑Yes ❑No '0 Unknown <br /> in.from to ft. ❑Yes 0 No ❑Yes ❑No 0 Unknown( <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE C 9 / <br /> Well owner's mailing address if different than property owners address indicated above Screen from /10 to / / 7ft. Open Hole from to ft. \ <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill Xio Obstruction <br /> 1 of 2 <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes 0 No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring 4,Type di- <br /> METHOD Type❑ Removed lot Present ❑Other <br /> USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> Plo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <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 lbs.,one bag of bentonite w 50 lbs.) <br /> Grouting Material ,011144/ L!—///6 from 0 to /99 ft. yards /C6 bags <br /> from to ft. yards bags <br /> from 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 XNo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION XNo <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 Co, Inc. 27172 <br /> Contractor BusinessName License or Registration No. <br /> /V/ 1 i '� /G - 03 <br /> d e res to i SignalDate <br /> LOCAL COPY H 9 fl S A 7 <br /> Name of Person Sealing Well or Boring yY`, <br />