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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnes t NoWell and Boring H 359155 <br /> SealiCounty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Hennepin Minnesota Statutes,Chapter 1031 Low -series Noi <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 35 SW SE SW - z. - 1,f 11 '..1 2 . <br /> GPS LOCATION-decimal degrees(to four decimal places) <br /> Depth at Time of Sealing // ft. Original Depth 242 D 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 /> r� North <br /> / ,..,. WELL/BORING k]Measured Date Measured - Z i /i' ❑Estimated <br /> 541 North Strom Rd, Orono 55391 /Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or •ing <br /> in section grid with"X" location,showing pro. r, ❑Temp.Env.Well ❑Other /AU ft. below ❑above land surface <br /> lines,roads,and build) e- <br /> N CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> ---'-----1,----- --------- WELLHEAD COMPLETION <br /> Outside:�Pitless Adapter/Unit ❑At Grade Inside: Ill Basement Offset <br /> •--i--- -- <br /> W <br /> 'h Mileill i ❑Well Pit ❑Buried ❑Well House <br /> I p ❑Well Pit <br /> N El Other <br /> g ❑Buried <br /> I t Mile .�N <br /> ����,,� ❑Other <br /> For multiple temporary environmental wells,pro at& location CASING(S) <br /> information,a site sketch,and geology on a separ trISSe Diam�e1ter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME l in.from :� to /1 Lift. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Property owl nnerjs�mailing address if different than well location address indicated above in.from to C, ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> L" 'S. ...0Z SCREEN/OPEN HOLE f' <br /> Screen from to ft. Open Hole from /`- O`/ to 426 ft. <br /> WELL OWNER'S NAME/COMPANY NAME <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) l3 V< t 'Ai( '.' - •14 7U y/! <br /> Obstructions removed? V Yes ❑No Describe /, r'' i/t ti C -T <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS TION <br /> ❑NotPresent resenRemovedSealing ❑ <br /> FOORMRMATION FROM TO Pt, Prior to Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type �/I l /2'7i if/) <br /> f-,-,.)/7 ,F 7- r} 3 c,' METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> to Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> i7 1,-."Or -?7' y//I 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? ❑Yes pee° TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Materiallf ii ,{; (fade, ,i,% from C% to t/ll 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 cileo 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 /> lit..)t`- Fa✓.w V'y 13 C 1-3,,,, ._/it- `01// <br /> / Don Stodola Well Milling Co., Inc. 1691 <br /> , <br /> • �/t /) i r�1 f i) curl ��y�� ! `/ '/ Licensee Business Na e License or Registration No. <br /> 17 T%'7Yl i> , -7.f! /wFi/ /�� ./ V . 0- dG - Ia <br /> itl,,(s 424) /ifhe."s#nta(ve SW:Tr-ore Certified Rep.No. Date <br /> LOCAL COPY " 359155 % - <br /> Name of Person Sealing Well or o <br /> HE-01434-16 ID#53159 t 7ertR <br />