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WELL OR BORING LOCATION ,A. MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring o. '' 305185 <br /> County Name WELL AND BORING SEALING RECORD Minn'eso a Unique well No. <br /> Q�1.e <br /> wnp* Minnesota Statutes,Chapter 1031 or W-series No. <br /> p f (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 31 SN A& B U N 1 Z <br /> GPS Latitude degrees minutes seconds Depth Before Sealing 435 _ft. Original Depth_ ft. <br /> LOCATION: Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location L^ingle Aquifer ❑Multiaquifer <br /> 125 Turnha,n Rd Orono,. MNWELL/BORING $&easured ❑Estimated Date Measured��i,rG lJI7� <br /> WWater-Supply Well ❑Monit.Well t <br /> Show exact location of well or boring JSketch map of well or boring <br /> in section grid with"X." �� location,showing property [:1 Env.Bore Hole [I Other "� ft. below E]above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> Steel ❑Plastic ❑Tileh <br /> ❑Other <br /> "J-----T"----f-----f-- WELLHEAD COMPLETION <br /> W ET <br /> IOutside: El Well House ElAt Grade Inside: Xasement Offset <br /> 'h Mile � ❑Pitless Adapter/Unit ❑Buried LlWell Pit II, <br /> --r- ---•-- 1 --- ❑Buried <br /> 3 <br /> ' Well Pit <br /> I---1 Mile y )( ❑Other LJ Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> f Diameter a Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if differ nt than well location address indicated above in.from_ to ft. ❑Yes XNo ❑Yes ❑No ❑Unknown <br /> 127 R County Rd C in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Little Canada,. lei. 5511 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from to A4.345 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> )?ods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill [-]No Obstruction <br /> Type of Obstructions(Describe)—./sJ4� N_ �► ��"�� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes El No Describe <br /> FORMATION <br /> If not kn wn,indicate estimated formation log from nearby well or boring. PUMP_ n <br /> J Type,jF ! U fine <br /> ' �6emoved ❑Not resent ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> (VNo 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 /> I <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> r � /� <br /> Grouting Material A/G 46WII5J from�jo to�'� ft. yards Go 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 Xo 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 CO.s. INC. 1691 <br /> Licensee Business Name License or Registration No. <br /> C e esentative Sign Certified Rep.No. Date <br /> LOCAL COPY H305185 <br /> v (wf <br /> Name of Person Sealing Well or Boring <br /> HE-01434-12 IC#140-0423 s/asR <br />