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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H <br /> County Name WELL AND BORING SEALING RECORD MinnSealiesota 231346 <br /> Minnesota Unique Well No. <br /> HennepinMinnesota Statutes,Chapter 1031 ooreW seN es�No. <br /> t <br /> Tenship Name Township No. Range No. Section No. Fraction(sm-).Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 20 24-0045 v. % S LT/3. 04/ <br /> GPS Latitude degrees minutes seconds /-f} f / <br /> LOCATION: Depth Before Sealing ea ft. Original Depth ( )f./ ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL — <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ASingle Aquifer 0 Multiaquifer <br /> 26147ZZTPI AVP ry�� WELLL/BORING XMeasured 0 Estimated <br /> / Oronn 55191 >/''''ater Supply Well 0 Mont.Well <br /> Show exact location of well or bonng Sketch map of well or burin. <br /> in section grid with"X" location,stowing prope r 0 Env.Bore Hole 0 Other Nt)NEft. *low ❑above land surface <br /> N lines,roads,and buildi o _ f` <br /> 1 CASING TYPE(S) <br /> 1STSteel ❑Plastic 0 Tile ❑Other <br /> w^ r , ' ' E v WELLHEAD COMPLETION <br /> Outside: 0 Well House Inside:)?'Basement Offset <br /> I I I I Led, —rNN <br /> I tt� �\ ❑Pitless Adapter/Unit 0 Well Pit <br /> S <br /> 0 Well Pit 0 Buried <br /> Ili—t mkt-- 111I, <br /> 0 Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAMEg CASING(S) <br /> Gordan AmundsonAmundson952-4 952-471-7700 Diameter Depth <br /> ` Set in oversize hole? Annular space initiallyinitiallygrouted? <br /> Property owner's mailing address if different than well location address indicated above2 r in.from U. ) 5(44_ <br /> yhlo <br /> 2 of 2 to ft. ❑Yes <br /> /` 0 Yes 0 No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes 0 No ❑Unknown <br /> in.from to ft. ❑Yes 0 No 0 Yes 0 No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from56 <br /> to �> I.ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> El Rods/Drop Pipe El Check Valve(s) I9/Debris <br /> ,,rrr 0 Fill 0 No Obstruction <br /> V <br /> Type of Obstructions(Describe) /:-kJ f <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? SDIC^��¢ r� /� <br /> FORMATION /�Yes El No Describe rJ <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> drift 0 60 Type <br /> El Removed XNot Present ❑Other <br /> � / <br /> METHOD, USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> yr No Annular Space Exists ❑ Annular space grouted with tremie pipe 0 Casing Perforation/Removal <br /> /` in.from to ft. ❑ Perforated El Removed <br /> in.from to ft. El Perforated El 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 Maten94rom 6 to ft. yards .. 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 <br /> Other unsealed and unused well or boring on property? 0 Yes '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 Co,. Inc. ;27172 <br /> Contractor Business Name License or Registration No. <br /> eg' <br /> „"''- / - 1-6-05 <br /> Auef¢Presentat Signature• Date <br /> LOCAL COPY H 231346 Jim Anton <br /> Name of Person Sealing Well or Boring <br />