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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 6 5 8 3 2 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. <br /> County Name Minnesota Unique Well No. <br /> p <br /> /� Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin i (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) Date SealedDate Well or Boring Constructed <br /> Orono 117 23 02 NB SE NW s/2 S /1? <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing / ft. Original Depth ft. <br /> Latitude Longitude <br /> ADUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> Measured Date Measured 5�i/) Mr'❑Estimated <br /> 1250 Woodhill AVe, Orono WE LJBORING <br /> Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well orb ring LQJ <br /> in section grid with"X:' loco io sh g prop Temp.Env.Well ❑Other ft. below ❑above land surface <br /> N Ines,rroas <br /> a buddl s. CASING TYPE(S) <br /> t IySteel ❑Plastic ❑Tile ❑Other <br /> WELLHEAD COMPLETION <br /> W ET <br /> t\� <br /> _ _ __ I ` Outside: hitless Adapter/Unit ❑At Grade Inside: [11 Basement Offset <br /> 'h Mile ❑Well Pit ❑Buried ❑Well House <br /> r 1 ❑Other ❑Well Pit <br /> s ❑Buried <br /> 1 Mile { <br /> 1 ❑Other <br /> For multiple temporary environmental wel , ro de additional location CASING(S) <br /> information,a site sketch,and geology on parate page. Diameter / Depth f Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME top <br /> lin.from O to_ _ft. ❑Yes XNo ❑Yes ❑No ❑Unknown <br /> Prope o . :Ir."' if.'-". '. .. . .'1• a.:es'" . r. in.from to ft. ❑Yes ❑No ['Yes ❑No ❑Unknown <br /> 11415 Valley Dr in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Rogers, MN 55374 SCREEN/OPEN HOLE <br /> f <br /> Screen from /402, to/eddy 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 y Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)„ 4/4. !b( ¢ igvin <br /> dop <br /> Obstructions removed? 'es ❑No Describe <br /> -- - - - - - - --- - PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present Present,Removed Prior to Sealing <br /> FORMATION ❑ ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type sue pu fr <br /> • / METHOD USEDTOSEAL ANNUtA <br /> CI <br /> R SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> /' s/ (�>ft 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 No TN# <br /> GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) <br /> 4 4 <br /> Grouting Material C4/ om_e_ to,./66 ft. yards /3 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? LI YesXNo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <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 N-meLicense or Registration No. <br /> i <br /> 'd' -e."s•n at ve Si. a re Certified Rep.No. Date <br /> LOCAL COPY H 3 5 8 3 Name of Peron lin W ll /. 0".S � <br /> 6 2 s Sea g e or Boring! <br /> HE-01434-16 ID#53159 : 9n7R <br />