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.. T ;_ �. . .. s ..� . . . . .. . . .. . . . . <br /> y�lE�!pR�80RING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 2 6 Q 2 3 9 <br /> ` WELL AND BORING SEALING RECORD Minnleso a�Unique Well No. <br /> County Name <br /> f�rmepin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leava Dlank if no�knov�n) <br /> Township Name Township No. Range No. Section No. Fraction(sm.�Ig.) Date Sealed Date Well or Boring Constructed � <br /> Orono I17 23 02 2l1-0019 �j <br /> GPS Latitude degrees minutes seconds Depth Before Sealing ��'� < ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ����[ ��,/ <br /> WE�UBORING _ Measured ❑Estimated Date Measured <br /> � ���Water-Supply Well [Monit.Well � <br /> Show exact location of well or boring Sketch map of well or oring �Env.Bore Hole r,���Other �� ft. �below L]above land surface <br /> in section grid with"X' location,showing prop rty <br /> lines,roads,and buildi s. <br /> N �� CASING TVPE(S) <br /> ��- � � � � <br /> . � , , , ,y <br /> --•-- ---�-----�---�- <br /> ��,j �Steel ❑Plastic ❑Tile ❑Other _ - <br /> • <br /> ` "'--' —�------`-----`-- WELLHEAD COMPLETION <br /> W : ; ; ; ET <br /> � � � � Y Outside: ❑Well House �At Grade Inside: [�Basement Offset <br /> � --�--- --�-- --�—--%-- � <br /> 'k nniie �� �,Pitless AdapledUnit ���Buried ❑Well Pit <br /> ' --;-- --;----%-----;- I Y _ Buried <br /> - L / � ❑Well Pit �Other <br /> � S � � <br /> �1 Mile� ;�`..;��' ❑Other _ <br /> PR R NE NAMEICO P NY NAME CASING(S) <br /> °�.�t�l" `�e�s�cf <br /> P Di rr�tyr� � Depth t � Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if diflerent than well location address indicated above �/ /� �� <br /> F in.from 'V to�ft. L;Yes �No ❑Yes ❑No ❑Unknown <br /> � �. ai)l)Yc <br /> in.from to _ft. ❑Yes �`i No ❑Yes ❑No i_]Unknown <br /> in.from_ to_ ft. ❑Yes ��i No ❑Yes ❑No U Unknown <br /> �� WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE/ � 1 <br /> i Screen from /t• � to �C�� ft. Open Hole from to ft. <br /> Well owner's mailing address if different than property owner's address indicated above — � <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill �No Obstruction <br /> �. Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? �Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. <br /> Type <br /> � ,��� <J ��` ---- <br /> �^!Removed �Not Present (�Other__ .____ <br /> � M�E/THOD USEDTO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOIE: <br /> �No Annular Space Exists ❑Annular Space Grouted with lYemie Pipe ❑Casing Perforation/Removal <br /> in.from __to_________ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> �+y/y� �'" I <br /> Grouting Materiai!"�I�+T£_';///���from � to ��� ft. yards� � _ 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 SEALING Other unsealed and unused well or boring on property? �Yes � No How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information conlained in this report <br /> is true to the best of my knowledge. <br /> Don Stodola Well bcilling c�,,_7�,___1�4L <br /> Contracror Busin s me License or Registration No. <br /> �' -�-. /.� %/- �:� 'l <br /> rtifi� epresentative Sig ature Certified Rep.No. Date <br /> � --- ?''��.i.��'�:.L���„a..'-"�.�,/ <br /> LOCALCOPY H 2 6 O Z�w/ <br /> Name ol Person Sealing Well or Boring <br /> HE-01434-09 IC#140-0423 siosa <br />