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Minnesota Well and Boring <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. H 12 0 0 7 3 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique No. <br /> RennePtn Minnesota Statutes.Chapter 103/ or W-series No. <br /> (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm. .Ig.) Date Sealed Approximate Date Well <br /> Orono �!1i8 23 31 170 `/f•, a 4, bEC ^5 or Boring Constructed <br /> Numerical Street Address or Fire Number and lCity <br /> �of Well or Boring LocationW " / / <br /> .. 4045 Waterton' Rd, Orono Depth Before Sealing ft. Original Depth ft. <br /> Show exact location of well or boring Sketch map of well or boring Static Water Level X Accurate <br /> in section grid with"X". location.showing property lines. <br /> N roads.and buildings. CIApproximate <br /> If- r <br /> -——— <br /> Single Aquifer ❑Multiaquifer I ft. X below above land surface <br /> I <br /> 1 CASING TYPE <br /> W E <br /> I 1� <br /> I /L7�Steel CIPlastic 0 Tile 0-Other <br /> 1 e mile <br /> / <br /> SScreen from to ft. Open Hole from to ft. <br /> Imo—1rnil �1 I �O.B/STRUCTION/DEBRIS/FILL <br /> Jam' <br /> PROPERTY OWNER'S NAME Obstruction 0 Debris ❑Fill <br /> Bollig Excavating 938.4133 <br /> Type of debris/obstructionZA/' • E• IAL/ . <br /> Mailing Address if different than property address indicated above. <br /> Attn: Dan Obstruction/Debris/Fill removed?, Yes ❑No <br /> 11401 Cty Rd 3 PUMP <br /> Hopkins, )tl 55343 <br /> ❑Removed _Not Present 0 Other <br /> CASING <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO <br /> FORMATION <br /> Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> If not known.indicate estimated formation log from nearby well or boring. // <br /> DriftIt 0 9 in.from to �� ft. • 0 Yes �No ❑Yes 0 No CI Unknown <br /> i► • in.from to ft. ❑Yes 0 No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes 0 No ❑Yes ❑No 0 Unknown <br /> --- _ --- - . -- - METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XNo Annular Space Exists <br /> ❑Annular space grouted with tremie pipe • <br /> -- - ❑Casing Perforation/Removal <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. ❑Perforated 0 Removed <br /> -- - Type of perforator <br /> ❑Other <br /> GROUTING MATERIAL <br /> Grouting material/V.'/C64:1-1"" from Q to 90 ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> UNSEALED WELLS AND BORINGS <br />/- Other unsealed well or boring on property? 0 Yes XJo <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 is <br /> true to the best of my knowledge. <br /> Dan Stodola Well Drilling Co., Inc. 21172 <br /> Contractor Business Name // License or Registration No. <br /> i 12- 45 . <br /> /7 <br /> the.Re resentative Signature Date <br /> LOCAL COPY H 1.2 0 0 7 3 Namea <br /> Jim <br /> L3 of Person Sealing Well or Boring <br /> HE-01434-01 <br />