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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 7 5 4 5 5 <br /> WoE ri o NamSealinsNo. <br /> BORING LOCATION WELL AND BORING SEALING RECORD Minnesota Well No. <br /> Cq �t e <br /> Minnesota Statutes,Chapter 103 or W s eries No. <br /> L�1.lYi�EPIA <br /> Township Name Township No. Range No. Section No. Fraction(sm.- Ig.) Date Sealed Date Well or Boring Constructed <br /> DRUN0 117 23 10 Sw'AN Nt - -' A 15 <br /> GPS LOCATION-decimal degrees(to four decimal places) y -' <br /> Depth at Time of Sealing �:r) ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer _ <br /> WELL/BORING yMeasured Date Measured ✓ `- iii Estimated <br /> 1150 Heritage Ln Orono, *1Nf7JWater-Supply Well E]Env.Well <br /> Show exact location of well or boring Sketch map of well or boring (/),- .4 <br /> / <br /> in section grid with"X" _ location,showing property ❑Temp.Env.Well ❑Other (!1 ft. below ❑above land surface <br /> lines,roads,and buildings. <br /> NI 1'. ,..4,- CASINGTYPE(S) <br /> - • ` Cr <br /> J �! Steel ❑Plastic ❑Tile ❑Other <br /> --------'---•------------ `^� (W�ELLHEADDtCOMPLETION <br /> w I I E T �{ , \ Outside:Ar Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> '/,Mi. ) 1 ❑Well Pit ❑Buried ❑Well House <br /> --- <br /> t ❑Other ❑Well Pit <br /> s ❑Buried <br /> I 1 Mile I 1. <br /> ❑Other <br /> For multiple temporary environmental w. provide additional location CASING(S) <br /> information,a site sketch,and geology o .a eparate page. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY�{ NAME.(( Lit{ 'Tj (� in.from r_'3 to / 79 ft. ❑Yes y No ❑Yes ❑No ❑Unknown <br /> gti ff 4 wv.AIQdSRt dl <br /> Property owner's mailin a di an ad ,ii ibated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 10425 Bluff Road in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Eden Prairie,. t4( 55347 SCREEWOPEN HOLE <br /> WELL OWNER'S NAME/COMPANY NAME Screen horn f 7 j to /r' 3 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above 'Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) d•,.--� - .— <br /> Obstructions removed? ' Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present Present,Removed Prior to SealingOther <br /> FORMATION ❑ ❑ <br /> If not known,indicate estimated formation log from nearby well or boring. Type , 't r ,. aJ S. ..i ..a- <br /> ,r-y A-� �1 !-t 3 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> CEJ •.i t fiL_ Pipe Space Grouted with Tremie K No Annular Space Exists ❑Annular p ❑Casing Perforation/Removal <br /> 1 Casing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑YesNo TN# <br /> -- - GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Materia 0,4 l)0-em--r.:. from (') to /e--3 ft. yards_ _ bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> is true to the best of my knowledge. <br /> DON STODOLA WELL DRILLING -CO. , INC, 1691 <br /> Licensee Business Name // License or Registration No. <br /> ` ` '� 'X- 553 <br /> dints eSiyna`fu i Certified Rep.No. Date <br /> LOCAL COPY H 3 7 5 4 5 5 �, ,_r,�.,_4 / _APA) <br /> Name of Person Sealing Well°Oaring l <br /> HE-01434-16 ID#53159 '---' 9/17R <br />