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F <br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 6 2 8 9 4 <br /> WELL OR BORING LOCATION Sealing No. <br /> CountyrJame WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W W-a eries No. <br /> not known) <br /> Towns ip amii Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed <br /> 11 <br /> Orono 117 23 06 N TA - a//8 hi <br /> GPS LOCATION—decimal degrees(to four decimal places) • <br /> Depth at Time of Sealing / ft. Original Depth ft. <br /> Latitude Longitude <br /> RA IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer Ill Multiaquifer <br /> 480 Park Ave, Orono 55356 WELL/BORING Measured Date Measured /jIL � ❑Estimated <br /> Water-Supply Well ❑Env.Well r <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property ❑Temp.Env.Well ❑Other _ S ft. 'below ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> e <br /> Steel ❑Plastic ❑Tile ID Other <br /> .__1___.__a__ -----:___ 4 WELLHEAD COMPLETION <br /> W E T �t` t <br /> I I Outsider Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> il <br /> ❑Other❑Well Pit ❑Buried ❑Well House <br /> ❑Well Pit <br /> s ❑Buried <br /> I 1 Mile—❑ ❑Other <br /> For multiple temporary environmental wells,p vide addit nal location CASING(S) <br /> information,a site sketch,and geology on a swarate page. DiamEt�r� / Depth / Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME X77// in.from 0 to_4562_ft. ❑Yes KNo ❑Yes ❑No <br /> ❑Unknown <br /> Props ow�rs mar ddress if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE <br /> r I <br /> WELL OWNER'S NAME/COMPANY NAME Screen from 40_to/GPO ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑FillNo Obstruction <br /> Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO ;KNot Present Present,Removed Prior to Sealing <br /> FORMATION �l ❑ El Other <br /> ,,,...,..e <br /> If not known,indicate estimated formation log from nearby well or boring. Type <br /> d <br /> 0 ii„, METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> V uu ro Annular Space Exists ❑Annular Space Grouted with Tremie Pipe El Casing Perforation/Removal <br /> sing 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 No TN# <br /> GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) <br /> / /_ I <br /> Grouting MateriayI�r /2i4 <br /> ( /Tfrom� to/6o4) ft. yards 43 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 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 /> ',� .3 / 9 <br /> C- I, -e.resen ative Signature Certified Rep.No. Date <br /> LOCAL COPY H 3 6 2 8 9 4 Name of Person Sealing Well or Borin \ CYw <br /> HE-01434-16 ID#53159 f 9/1711 <br />