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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring HSeal261702�} O/� <br /> ng <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnlesso aoUnique Well No. L 1 G <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Henmpin (Leave blank N not known) <br /> Township Name Township No. RangeNo. Section No. Fraction(sm. Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 1 32 25' j-&A N 07 <br /> GP Latitude degrees minutes seconds Depth Before Sealing �"7 ft. Original Depth ft. <br /> I Longitude degrees minutes seconds IFER(S) STATIC WATER LEVEL <br /> eri res.or Fire Number and City of Well orLocation Single Aquifer ❑Multiaquifer <br /> WELL/BORING Measured ❑Estimated Date Measured..)/?/�M <br /> Wa to Blvd Oron Water-Su <br /> ppIy Well ❑Montt.Well r <br /> Show exact location of well or boring h map of well boring �,,/ <br /> in section grid with"X.' �' loca roperty [I Env.Bore Hole ❑Other ft. JEy below [Iabove land surface <br /> roads,a uildings. <br /> N CASING TYPE(S) <br /> Steel [_]Plastic F1Tile ❑Other <br /> ` <br /> WELLHEAD COMPLETION <br /> W EI <br /> Outside: ❑Well House ❑At Grade Inside: ❑Basement Offset <br /> h Mile X Pitless Adapter/Unit ❑Buried ❑Well Pit <br /> T + d <br /> < ❑Burie <br /> s � 4 '6� ❑Well Pit <br /> -1-78-445. <br /> ❑Other <br /> TH1� A 178+45 110' T Other <br /> PROPERTY <br /> OWNER'S NAME/COMPANY NAME CASING(S) <br /> M WT Dia et�r� /�I Depth r Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different thaniwe�lllocation address indicated above in.from E,r to�5 ft. ❑Yes )(No ❑Yes ❑No ❑Unknown <br /> C/(l�arl bolander So 13 CQmp$ny in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 251 Starkey St <br /> St Paul, MN 55107 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 195' to ft. Open Hole from_ to ft. <br /> OBSTRUCTIONS - <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Descri1beL--7-JhlK,< "O'X— 11L 191)4"40 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR <br /> FORMATION FROM TO Obstructions removed? es E]No Describe_ <br /> - --"— <br /> PUMP C !? <br /> If not known,indicate estimated formation log from nearby well or boring. j Type 7 o fe) P- <br /> D ` Removed ❑Not Prelent ❑Other <br /> ( 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 /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 lbs.) <br /> Grouting MaterialW6, f e,061e—f m tol 2q ft. yardsj'� bags <br /> from to ft. yards bags <br /> from to Ir 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 Xo How many? <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 <br /> is true to the best of my knowledge. <br /> Doa Stodola Well Drilling Co,. Inc. 1691 <br /> Contractor Business Name License or Registration No. <br /> 00, <br /> tiff F7epresentative at a Certified Rep.No. Date <br /> LOCAL COPY <br /> H261702 <br /> ���Qn-v�i Yv.I...Ilrv�✓ <br /> 2 6 17 0 2 <br /> Name of Person Sealing Well or Boring , <br /> HE-01434-09 ICa 140-0423 6/OeR <br />