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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring WELL OR BORING LOCATION Sealing No. H 169381 County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. 8innopin Minnesota Statutes,Chapter 1031 or W-series No. (lam WW,If not known) -- Township Name Township N . Range No. Section No. Fraction(sm.-,Ig.) Date Sealed Date Well or Boring Constructed Orono 117 23 05 23-0043 2. AUC' 00 Numerical Street Address or Fire Number and City of Well or Boring Location Q s E 264 M looks Strast, Orono Depth Before Sealing 9U ft. Original Depth 618 ft. Show exact location of well or boring. R53"g� Tar Sketch map of w boring AOUIFER(S) STATIC WATER LEVEL - in section grid with"X'. ! location, shown rt Sin le A uifer lines,roads,an byi ' s. g q ❑ Mulbaquifer ,. N yJ ` WELUBORING Measured ❑ Estimated Nater Supply Well ❑Monit.Well f T — T lhJ �// ❑ Env.Bore Hole ❑Other 7y ft. ytbelow 0 above land surface i W---r---,----,-----, -"E CASING TYPE(S) • I I --[---i----i------I--- T )(Steel ❑ Plastic ❑Tile ❑Other i I . I I )tmite K --- , a CASING(S) Diam tprt Depth / Setin oversize hole? Annular space initially grouted? ll�� S - (�r. /� Com/) 11�—1 mire "T�1 in.from a to ?• ft. ❑Yes X/ho ❑ Yes 0 No ❑ Unknown PROPERTY OWNER'S NAME in.from to ft. 0 Yes ❑No. ❑ Yes ❑No 0 Unknown Sollig 6 Sons Property owners mailing address if different than well location address indicated above. in.from to ft. D.Yes ❑No ❑ Yes 0 No 0 Unknown Jim 938-4133- SCREEN/OPEN HOLE U/ 11401 Cty Rod 3 / �j Q / Screen from q 7 to !Cl ft. Open Hole from : to ft. Hopkins, KM 58343 OBSTRUCTIONS WELL OWNER'S NAME X Rods/Drop Pipe 0 Check Valve(s) ❑Debris ❑ Fill 0 No Obstruction M Well owners mailing address it different then property owners address indicated above. Type of Obstructions(Describe) �" —#' / 11_ , , f9 , Obstructions removed? ( Yes 0 No Describe PUMP /� /� Type 5 !- uIn $- a GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO R.clemoved ❑ Not Present ❑ Otfier FORMATION II not known,indicate estimated formation log from nearby well or boring. - METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: lliCo Annular Space Exists WI ❑Annular space grouted with tremie pipe ❑Casing Perforation/Removal in.from to ft. 0 Perforated ❑ Removed in.from to ft. 0 Perforated 0 Removed Type of perforator ❑ Other GROUTING MATERIAL(S) (One bag of cement.94 lbs.,one bag oftbentonite.50 lbs.) Grouting Material ili-* cemf.„1FoFn 0 to ie fl. yards 8 bags tfrom to ft. yards bags from to ft. yards. bags . from ' to_ ft. yards bags REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING OTHER WELLS AND BORINGS Other unsealed and unused weltrtboring on property? 0 Yes VW How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION • This well or boring was sealed in accordance with Minnesota Flutes,Chapter 4725. The information contained in this reporf'is true to the best of my knowledge. Don Stodola WO it Drilling Co., Inc. 27172 Contractor Business N e License or Registration No. Auth ed presentative Signature Date \ H LOCAL COPY 169381 Name of Person Seel;jj ell or Boring .