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WELL OR BOOM LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Bc <br />WELL AND BORING SEALING RECORD Seating �r 126521 <br />County NameWELL Unique No. <br />Hennepin Minnesota Statutes, Chapter 1031 or W-senes No <br />I�N�e Marl a rqr ono+*, L— <br />Township Name Town" No Range No Section No Fraction ism i Ig I Date Sealed Date Well or Boring Constructed <br />Orono 11 2 02 1 4r3-002 r- <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />1045 H Ferndale rd, Orono Depth Before Sealingh original Depth 2co it. <br />Stow exact location of wall or boring Sketch map of well or boring A ER(S) STATIC WATER LEVEL <br />in section gnd with -X- ia.ahon show'ng property mgie Agwtrn j 4lulfcfquAer <br />N ' 1 i,nec roads, antl bu�IdNgs <br />WE ORING X—swed El Estimated <br />Water Supply Well ❑ Mond Wcll f <br />(-] Env Bore Role ❑ Other _-- -- -- _ G If ;Weow ❑ above land surface <br />W - %•- •?- •i-• E _-_ �... CASINGTYPEIS) <br />"E- •i-• -�-- -�-- ( ' Steel ❑ Plastic ❑ Tile ❑Other <br />r � I <br />LmM <br />PROPERTY OWNERS NAME <br />VfeQariy ewnais mailing address d afferent than wail lo(alion address . o—ted above <br />1055 14 Ferndale Rd <br />Orono, 11N 55391 476-1720 <br />WELL OWNER'S NAME <br />WON owns mtlrq address it dlffwent than property owners addrau ,nO,caled above <br />OEOLOW,AL MAMMAL I COLOR SSOI FORMATION I FROM I TO <br />rot krom , xtdtala aaMriand lomiaaon leg hom nearby was or boring <br />CASING <br />Diameter Dept <br />Set in oversize hale' <br />Annualar space initially groutedl <br />in Irom to �� It <br />❑ Yes XlNo <br />❑ Yes ❑ No ❑ Unknown <br />in fr— to h <br />❑ Yes ❑ No <br />❑ Yes ❑ No ❑ Unknown <br />in from to h <br />❑ Yes ❑ No <br />[J Yes ❑ No ❑ Unknown <br />SCREENlOPEN HOLE <br />% 6' cat <br />Screen from to h Open Foie <br />from to <br />if <br />OMTRUCTONDEORMLFILL <br />Obstruction ❑ Debits ❑ Fill ❑ No Obstruction <br />Type of Obstruction-DetxlLFlll 1 1A-' <br />1:24IM P <br />ODstruclaNDebrlaFdl removed? Ky. ❑ No <br />PUW <br />Type - <br />WRemoved ❑ Not Presets ❑ Other <br />METHOD USED TO SEAL ANNULAR SPACE METWEEN 2 CASINGS, OR CASMW AND 1011E NOLE <br />No Annual Space Exits <br />- ❑ Annular space grouted with frame pope <br />J ❑ Casing PertorahoniRanoval <br />in from to h ❑ Pentoralsd ❑ R.niovad <br />n from to h ❑ Parbnated ❑ Rentotr.d <br />Type of perforator <br />❑ Other <br />Grouting MaterialIf <br />Yard. <br />Iron, _ to h Yards baps <br />from to it _ Yards bap <br />from to _- _ it Yards bap <br />PONAMPAk SOLV CE OF DATA, DMRCULTIES IN t[AUIIO UNSEALED WELLS AND POMIGS <br />Other unsealed well or boring on property? ❑ Yes X. <br />LICENSED OR REGWTEREO CONTRACTOR CERTIFICATION + <br />This well or boring was sealed in accordance with kknresols Rubs. CMpNr 4725 The oft ntoft Contained in it" rspot la <br />true to the best of my knowledge <br />Don Stodola Well Drilling co., Inc. 27172 <br />Contractor Business Isms License a, RepWr~ No. <br />A.mon•od Representative sWisture EE; DaY <br />LOCAL COPY <br />TH 126521 Name of Pbrsai Sealing, ~ or Bong <br />NE-0114" <br />,oilesR <br />