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• <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 34 4142 <br /> WELL AND BORING SEALING RECORD <br /> County Name Minnesota oUnique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> � chew blankit not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-»Ig.) Date Sealed Date Well or Boring Constructed <br /> or <br /> 117 21 06 S St Mi 21 OICT /& <br /> GPS LOCATION—decimal degrees(to four decimal places) � <br /> Depth Before Sealing („i,?f ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer /�/ <br /> W LL/BORING XMeasured ❑Estimated Date Measured silo*. MY <br /> 4780 North Ana Dr Orono y�A/ <br /> 1 ater-Supply Well ❑Monit.Well f <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other 'IS ft. Xbelow ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> {~ _if ! steel ❑Plastic ❑Tile ❑Other <br /> ---i--- --'---F--'------ { ^a t <br /> �1" { WELLHEAD COMPLETION <br /> w r-- E T* r`. _• Outside: ❑Well House ❑At Grade Inside: <br /> ❑Basement Offset <br /> ; 'h We <br /> ❑ ❑Pitless Adapter/Unit Buried ❑Well Pit <br /> S <br /> XWell Pit ❑Buried <br /> I1 Mile--1 ❑Other ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> +:i 1 pn Pnrei Lr Diameter t Depth Al Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above <br /> 3 <br /> a+�� in.from 'i to ft. ❑Yes No ❑Yes ❑No ❑Unknown <br /> Jl09 D to Ave S in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> St Louis Park, MN 55416 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r <p- , x r t <br /> ad <br /> Well owner's mailing address if different than pr iia' Ove Screen from to ft. Open Hole from to ft. <br /> _OQSTRUCTIONS <br /> JAN <br /> N 1 8 2017 Rods/Drop Pipe ❑Check Valve(s)Vavee( ❑Debris ❑Fill <br /> i7 ❑No Obstruction <br /> [����{n L <br /> Type of Obstructions(Describe) iA$�-OP S. F -e ,,f( , <br /> GEOLOGICAL MATERIAL COL'aA' ,I � � TO Obstructions removed? Yes ❑No Describe �•r <br /> If n <br /> A _t known,indicate estimated formation log from nearby well or boring. PUMPd <br /> Removed <br /> ❑Not Present 1 ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> 7777���� 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=lis.,one bag of bentonite=50 lbs.) <br /> Grouting Material dorcagier,.from 7 to 60 ft. <br /> yards iel 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 SEALINGOthXer unsealed and unused well or boring on property? ❑Yes I�No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION f <br /> 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 Bu Name License or Registration No. <br /> J _ f <br /> Az, <br /> :/.�f" ,{.#10;'- #� 0 .try).,�.� '/iG f <br /> ,Cfrt <br /> rfi Representative Signature Certified Rep.No. Date <br /> LOCAL COPY 34 4142 <br /> Name of Person Sealing Well or.Boring <br /> HE-01434-14 ID#53159 1 <br /> 5/13R <br />