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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 313286 <br /> Seal <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnleso aoUnique Well No. <br /> �iennepin Minnesota Statutes,Chapter 1031 or W serieskNo. <br /> Township Name Township No. I Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 05 Sit SW SE // 7&AK 12 <br /> 1 <br /> GPS Latitude degrees minutes seconds Depth Before Sealing /Q� ft. Original Depth _ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> � L]UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Bon Location Single Aquifer Multiaquifer <br /> 760 TonkawR Rd, Orono 5535 WELL/BORING X Measured ❑Estimated Date Measured SAZrot 6AN <br /> Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring �] <br /> in section grid with"X° location,showing property ❑Env.Bore Hole L]Other _i1�ft. �below [j above land surface <br /> N ``' lines,roads,and buildings. CASINGTYPE(S) <br /> ❑Steel XPlastic <br /> -]Tile ❑Other <br /> --i-----'------F--'--`' WELLHEAD COMPLETION <br /> , <br /> W E <br /> Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> h Mile j *itless Adapter/Unit ❑Buried ❑Well Pit <br /> T <br /> --------------Iil_ <br /> ❑well Pit ❑Buried <br /> ' s 71 Other <br /> 1 Mile ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Dia2jer Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailingaddress if different than well location address indicated above i1 <br /> y in.from to�U ft. Yes No Yes No <br /> �f ❑ � ❑ ❑ ❑Unknown <br /> P.O. Box 4W)726 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Blaine, Mn 55449 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> 7 ��/ r <br /> Well owner's mailing address if different than property owner's address indicated above Screen from��to ii ft. Open Hole from_ _to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check`Valve(s) ❑Debris/f ❑Fill El No Obstruction <br /> Type of Obstructions(Describe) ..L/V/l/��Sf <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes E]No Describe <br /> FORMATION <br /> If not nown,indicate estimated formation log from nearby well or boring. PUMP <br /> / Tyne <br /> llt7 Removed ❑Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XNo 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)�1 (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> T <br /> Grouting Material /yL../� elleCJ/ from 40' to/j , 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 XNo 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 <br /> is true to the best of my knowledge. <br /> Don Stodola Well Drilling CiI Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> i epresentative Signaturr Certified <br /> iRep.No. Date <br /> LOCAL COPY H 313286 <br /> Name of Person Sealing Well or B® <br /> ring <br /> IC#140-0423 - 5/12R <br />