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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring ■ <br /> Sealing No. 2181 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Hermepin 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->Ig) Date Sealed Date Well or Boring Const ru ed <br /> Orono 117 23 6 /& ) <br /> , 0 <br /> GPS Latitude degrees minutes seconds f Q <br /> Oil <br /> LOCATION: Depth Before Sealing ` ft. Original Depth ft. <br /> Longitude degrees minutes seconds UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location L.Kingle Aquifer ❑Multiaquifer ]( <br /> 473 Tonkawa Rd, Orow 55356 EL BORING Xleasumd ❑ Estimated <br /> ater Supply Well E]Monit.Well / <br /> Show exact location of well or boring Sketch map of well orb ring <br /> in section grid with"X" location,showing prope ty ❑ Env.Bore Hole ❑Other ft. below ❑above land surface <br /> N lines,roads,and buildin s. CASING TYPE(S) <br /> i <br /> ' 4 r Steel E]Plastic ❑Tile ❑Other <br /> W E ,� n WELLHEAD COMPLETION <br /> I Outside: <br /> ❑Well House Inside: E] Basement Offset <br /> �Pitless Adapter/Unit ❑Well Pit <br /> ` ❑Well Pit ❑Buried <br /> S /1 <br /> -rmde ' ❑ Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Dia t r Depth j Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above ! //�'� t <br /> in.from to /�2 ft. E]Yes o L]Yes ❑No E]Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from t0 ft. ❑Yes ❑ No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> / l <br /> Well owner's mailing address if different than property owner's address indicated above Screen from/42 toft. Open Hole from t0 ft. <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? E]Yes E] No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type <br /> ❑ Removed )<Not Present El Other <br /> HOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 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) (Onn}e'bag <br /> goofcement=94 lbs.,one <br /> //bag <br /> �ooff berr jonite=50 Ibs.) <br /> Grouting Material L`�� ��r+z�� ^">,frnm to . yards bags <br /> from to ftyards 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 Vo 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 /> Don Stodola Well Drilling Co., Inc. 27172 <br /> Contractor Busines,Name License or Registration No. <br /> uth r e Representative Signature Date <br /> LOCAL COPY h 218151 <br /> Name of Person Sealing Well or 6 frig <br />