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MINNESOTA DEPARTMENT OF HEALTH• Minnesota Well and Boring <br /> WELL OR BORING LOCATION Sealing No. H 279287 <br /> County Name •-, WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W a ek ries No. <br /> not known) <br /> Hennepin (Leave <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 02 ' W 'SE 'SW 9 `f U kI 7 I r <br /> GPS Latitude degrees minutes seconds Depth Before Sealina ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> ,A( UIFER(S) ST TIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ySingle Aquifer ❑Multiaquifer jI M` /�/)!� <br /> WELL/BORING Measured ❑Estimated Date Measured ''+r rte] <br /> 2095 Webber Rills Ed, Orono 55391 �tnfater-Supply Well ❑Monit.Well t <br /> Show exact location of well or boring Sketch map of well or boring ��//''�, ` 5 <br /> in section grid with"X." location,showing property ❑Env.Bore Hole ❑Other ft. below ❑above land surface <br /> N lines,roads, buildings. CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile Q Other <br /> -----' --"--" T WELLHEAD COMPLETION <br /> L <br /> W EI <br /> Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> 'h Mae 1,....i0❑Buried ❑Well Pit <br /> Pitless Adapter/Unit <br /> T 0 ❑Buried <br /> s \i ❑Well Pit <br /> ❑Other <br /> 1--t Mile---1 ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Thomas Sween Dille'?f f Depth / Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address it different than well location address indicated aboveq <br /> in.from o !.3 ft. Q Yes )(No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN/HOLE t I <br /> Well owner's mailing address if different than property owners address indicated above Screen from S � to ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe Q Check Valve(s) ❑Debris ❑Fill [(o Obstruction <br /> Type of Obstructions(Describe) <br /> i <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> If not kn wn,indicate estimated formation log from nearby well or boring. PUMP <br /> Type <br /> iv , •7❑Removed KNot Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> 'Vo 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 4 <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S)�� ((One bag of <br /> cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> AI e�/'rf�ffrom O f to / /�ft. / <br /> Grouting Material <br /> yards bags <br /> 9 <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 How many? _ <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION fff�f ����j. <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., Inc. 1691 <br /> Licensee Business/Name \ License or Registration No. <br /> ,,...2 •;(. <br /> i/: /- . 7- 9- Q 5, <br /> C rfrtrve•ntatif Signature Certified Rep.No. Date <br /> N's'NoLl."'".--' c....i. <br /> LOCAL COPY H 279287Name of Person Sealing Weff or Boring <br /> HE-01434-11 IC#140-0423 2/08R <br />