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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 35 9 097 <br /> WELL OR BORING LOCATIONSealing No. <br /> Name WELL AND BORING SEALING RECORD. <br /> County Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. /‘, 3 7 <br /> . p (Leave blank it not known( <br /> n <br /> Township Name Township No. Range No.,Section No. Fraction(sm.-•Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 .: 07 NS\NW SW el 4,//6, [I- ,a -79 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 17/ J ft. Original Depth I %V ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring LocationSingle Aquifer ❑Multiaquifer / <br /> Lane, <br /> Measured Date Measured ' ❑Estimated <br /> 4755 ' ikdiieN Lane Orono 55364 EWater-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or boring ❑Temp.Env.Well ❑Other / J ft. below ❑above land surface <br /> in section grid with"X" �� location,showing property r <br /> lines,road;and buil ings. CASING TYPE(S) <br /> N <br /> - -----y----i---- <br /> I ;iitfSteel ❑Plastic ❑Tile ❑Other <br /> --_4--_ -----!---------- WELLHEAD COMPLETION <br /> w E r <br /> T I OutsldeXitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'Iv Mile ❑Well Pit ❑Buried ❑Well House <br /> LII Well Pit <br /> i ❑Other <br /> s ❑Buried <br /> I----1 Miley "� ❑Other <br /> For multiple temporary environmental wells,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter��//�� Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from__ to_ �ft. ❑Yes •. No ❑Yes ❑No ❑Unknown <br /> Pro neo m!�RIQ`dtlEreslint RT11.eeell 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/HOLEE <br /> Screen from /9(O to /96 ft. Open Hole from to ft. <br /> WELL OWNER'S NAME/COMPANY NAME <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill {moo Obstruction <br /> Type of Obstructions(Describe) T <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUMP <br /> HARDNESS OR <br /> GEOLOGICAL MATERIAL COLORFORMATION FROM TO .Not Present ❑Present,Removed Prior to Sealing 0 Other <br /> If not known,indicate estimated formation log from nearby well or boring. JTyype <br /> ci Id+ " i Vo METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> J ' No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> Casing 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 Xfqo TN# ` <br /> GROUTING MATERIAL(S) (One bag of cementemya 94 lbs.,one bag of bentonite a 50 lbs.) <br /> Grouting Material/ea n�r/�7Pgfrdm0_ to_/ _ ft. yards /6 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 allo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION f <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 /> e ' r s n gnaturertifiedI'No.—/(ate <br /> LOCAL COPY H 3 5 9 0 9 7 Name of Person Sealing Well or�g` Li <br /> v. <br /> HE-01434-16 ID#53159 k' 9/17R <br /> r <br />