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r <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I I A O <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnesota No. <br /> well No. �} <br /> henne, in Minnesota Statutes,Chapter 1031 or W-series No. <br /> L+" (Leave dank if r known) <br /> Township Name Township No. Range No. Section No. Fraction(sm i Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 26 9 lun L Z Q r <br /> GPS Latitude degrees minutes seconds <br /> LOCATION: Depth Before Sealing ft. Original Depth ff. <br /> Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location 6 Single Aquifer ❑Multiaquifer <br /> WELUBORING Measured ❑Estimated <br /> 1099 Tana Water Supply Well ❑Monit.Well t <br /> Show exact location of well or boring Sketch map of well orb ring !��/ ,,,+++...``` <br /> in section grid with"X" 55356 location,s ovyingp ❑Env.Bore Hole ❑Other ft. Ex above land surface <br /> N <br /> lines,�rgand,buildi s. CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> T— -- - - ') WELLHEAD COMPLETION <br /> W - -, ,-- -- - E <br /> �f �f Outside: E]Well House Inside: E]Basement Offset <br /> &mid p�Pitless Adapter/Unit E]Well Pit <br /> '�-- i --i'- I t' !1 <br /> 1 —w� N ❑Well Pit ❑Buried <br /> S <br /> I f rr^,- F-1 Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diame r Depth r Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing a if iffier c ti dress indicated above / <br /> in.from t0 I ft. ❑Yes lo E]Yes ❑No E]Unknown <br /> in.from to ft. ❑Yes ]No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r / <br /> Well owner's mailing address if different than property owners address indicated above Screen from_ _ to_. _ft. Open Hole from W�to��ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill )KNo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM FORMATION TO Obstructions removed? ElYes ElNo Describe <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> .j M Type <br /> fes-_ ❑ Removed ANot Present ❑ Other <br /> '1 3 t1 f <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> r IQ`No Annular Space Exists ❑ Annular space grouted with tremie 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 lbs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material N �T`-I.—/n.":/✓'27rom 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 X. How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is <br /> true to the best of my knowledge. <br /> TION STODOLA WELL DRILLING CO. #. INC. 27172 <br /> Cont�,acto,Busine N;pe ,w License or Registration No. <br /> 240806 <br /> y Aut ze epresentative Signature- Date <br /> LOCAL COPY — <br /> Name of Person Sealing Well or Boring <br />