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W <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota a1NeU and Boring H I 362769 <br /> WELL OR BODING LOCATION o. <br /> WELL AND BORING SEALING RECORDMinneSealing <br /> Unique Well No. <br /> Bounty Name <br /> + Minnesota Statutes,Chapter 1031 oar series No. <br /> TownshipHennepk if not knavnt <br /> +n Township No. Range No. Section No. Fraction(sm.-4 Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 33 9E SE SE /243//8 <br /> GPS LOCATION-decimal degrees(to four decimal places) i <br /> Depth at Time of Sealing 2413 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 Locationyf)(Single Aquifer ❑Multiaquifer rf <br /> 2590 Watertown Rd, orono 55356 WELL/BORING 'Measured Date Measured S�/l1ITt--# El Estimated <br /> VrWater-Supply Well El Env.Well <br /> Show exact location of well or boring h map of well or boring ❑T <br /> in section grid with"X" loca n,showing property emp.Env.Well ❑Other 7 ft. [ elow ❑above land surface <br /> line roads,and buildings.N CASINGTYPE(S) <br /> , A <br /> --- - --. I I 04 Steel ElPlastic El Tile ❑Other <br /> ---;-----;-- --}-- + WELLHEAD COMPLETION <br /> W E� Outside:XPitless Adapter/Unit El At Grade Inside: ❑Basement Offset <br /> 'h Mile ❑Well Pit ❑Buried ❑Well House <br /> --t--;-'I.--------- 1 ❑Well Pit <br /> El Other <br /> ❑Buried <br /> 1--1 Mile--1�� El Other <br /> For multiple temporary environme,p ovi a-a oe CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter' , Depth e Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNNEER SS NAME/COMPANY NAME _6,_._.in.from a to 2...5q ft. El Yes ElYes No ❑YesNo El Unknown <br /> Pros mallfig dress it different than well location address indicated above in.from to ft. ❑Yes El No El Yes ❑No El Unknown <br /> in.from to ft. ❑Yes El No El Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE r <br /> • <br /> Screen from 2'x`3 to 26 3 ft. Open Hole from to 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 El Check Valve(s) ❑Debris ❑Fill Aflo Obstruction <br /> Type of Obstructions(Describe) <br /> Obstructions removed? El Yes El No Describe <br /> PUMP <br /> HARDNESS OR <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO Not Present ElPresent,Removed Prior to Sealing ❑Other <br /> If not nown,indicate estimated formation log from nearby well or boring. Type <br /> 0 6243 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> 4116— <br /> cv KNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ElCasing Perforation/Removal <br /> teasing Diameter <br /> in.from to ft. El Perforated ❑Removed <br /> in.from to ft. El 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= 4 lbs.,one bag of bentonite=50 lbs.) <br /> �,L r r <br /> Grouting Material#41602, '/I�IV/ from_to 240.3 ft. yards y/ 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? El Yes XNo 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 /> i <br /> ted pres ti a lure Certified Rep.No. Date <br /> 362769f` c �� 1 <br /> LOCAL COPY H Name of Person Sealing Well or Bor <br /> HE-01434-16 ID#53159 9/178 <br />