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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring o. H 108122 <br /> County Name <br /> WELL AND BORING SEALING RECORD Sealing <br /> Minnesota <br /> Unique No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-t.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 17 31-003 1- (-_ <br /> Numerical Street Address or Fire Number and City of Well or Boring Location r <br /> If <br /> 3785 Togo Rd VSA/ Jh77� 55391 Depth Before Sealing �j� ft. Original Depth sz ft. <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with X. location, showing property [)4ingle Aquifer ❑ Multiaquifer <br /> lines,roads,app buildings. <br /> N / :fi- j� v WELL/BORING >(1Aeasured E] Estimated <br /> ater Supply Well ❑Mont.Well <br /> {1 i <br /> Env.Bore Hole El Other <br /> ft. 'below Elabove land surface <br /> W --�----�-- 0--�-- --�-- E ( ( } CASING TYPE(S) <br /> ' ff � <br /> t <br /> ---- ----- --�-- --�-- i + Steel ❑ Plastic ❑Tile ❑Other <br /> Mile <br /> CASING <br /> Diameter Depth ' <br /> Set in oversize hole? Annualar space initially grouted? <br /> t mile T 'in.from </ to � ft. ❑ Yes tVmo ❑ Yes ❑ No ❑ Unknown <br /> PROPERTY OWNER'S NAME in.from _ to tt. ❑ Yes No ❑ Yes ❑No ❑ Unknown <br /> Paul Rimachendorfer 471-9014 <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> r <br /> Screen from to ft. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME <br /> Obstruction El Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill 446. iiiie �' f �iV"✓t <br /> Obstruction/Debris/Fill removed? 15<Yes ❑ No <br /> PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO ❑ Removed XNot Present ❑ Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XNo Annular Space Exits <br /> f <br /> ❑ Annular space grouted with tremie pipe <br /> ❑ 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) <br /> Grouting Material 4 —S,L— to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes XNo <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 /> Don Stodola Well DrilliriL Co., Inn. 27172 <br /> Contractor Business Name / License or Registration No. <br /> ho R Asenfg-t,v Signature. Date <br /> LOCAL COPY H <br /> 10812 -2 Name of Person Sealing Well or Boring <br /> HE-01434-02 10/95R <br />