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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing Minnesota <br /> Wt <br /> lI and Boring H 362799 <br /> NCounty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> � ppf Minnesota Statutes,Chapter 1031 or W s eriesk No. a /lag 5�3 <br /> TownsTi ricin Township No. Range No. Section No. Fraction(sm.–.Ig.) Date Sealed Date Well or Boring Constructed <br /> v. <br /> 0 1,17 23 06 8 S6 SR `I Aio <br /> he IF <br /> S - '7 - oma?G / 7GPS OC ION– decimaldegrees(to four decimal places) ,,, �j <br /> Depth at Time of Sealing / /( ft. Original Depth I / I ft. <br /> Latitude Longitude <br /> O IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> 780 Lakeview w fir, Orono 55364 WELL/BORING XMeasured Date Measured �rnF MI/ ❑Estimated <br /> Lii1SCv1 `ng vLa7 Ske J JPF Water-Supply Well ❑Env.Well i <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X." location,showing proper ❑Temp.Env.Well ❑Other ft. below ❑above land surface <br /> N Ines,roads,and bu'Idl CASING TYPE(S) <br /> l l l <br /> 1 <br /> I j r ❑Steel X.lastic ❑Tile ❑Other <br /> ---'--- - <br /> --F------t--- , 1 WELLHEAD COMPLETION <br /> w E— J <br /> �7 Outside: itless Adapter/Unit ❑At Grade Inside: II]Basement Offset <br /> %Mie ❑Well Pit ❑Buried ❑Well House <br /> ❑Well Pit <br /> Ts l 1 ❑Other <br /> //e ❑Buried <br /> f 1 Mlle I ❑Other <br /> For multiple temporary environmental wells,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter r , Depth , Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from 0 to (]3 ft. X Yes ❑No IWCYes ❑No ❑Unknown <br /> Prop clin Nara if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 18215 45th�AVeN, Ste D in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> ! ' <br /> Plymouth, T 55446 SCREEN/OPEN HOLE /� <br /> WELL OWNER'S NAME/COMPANY NAME Screen from /61 to/// ft. Open Hole from to ft. <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 ❑No Obstruction <br /> Type of Obstructions(Describe)Zili1/tie # 2' ¢ Ano <br /> Obstructions removed? )(Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type <br /> dfrift 0 1 METHOD 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 /> 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 o TN# <br /> GROUTING MATERIAL(S) (One bag ofofcement= 4 lbs.,one bag <br /> of bentonite=50 lbs.) <br /> Grouting Material��A7ef /from .Q/ to /NW ft. yards /511/ bags <br /> from 'i to ft. yards bags <br /> i <br /> from ) to ft. yards bags <br /> OTHER WELLS AND BORINGS ! <br /> Other unsealed and unused well or boring on property? ❑Yes' No 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 billing Co, Inc- 1691 <br /> Licensee Business Name License or Registration No. <br /> ert"d" .re a i wig -ture Certified Rep.No. Date <br /> H 362799 Jim Antoni' <br /> LOCAL COPY Name of Person Sealing Well or Boring <br /> HE-01434-16 ID#53159 9079 <br />