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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H. <br /> Sealing <br /> County Name 261703 <br /> WELL AND BORING SEALING RECORD Minnesota Well No. <br /> _ <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hf n (Leave blank it not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 32 '' '' '' <br /> GP A Latitude degrees_ minutes_ seconds Depth Before Sealing J ft. Original Depth ft. - <br /> L ICON: Longitu minutes seconds pUIFER(S) STATIC WATER LEVEL <br /> mer tregLAddress-or Fire Numbei arr4,q y of Well or B Location Single Aquifer ❑Multiaquifer O <br /> y�►,}� WELLBORING Measured ❑Estimated Date Measured /61 <br /> --_wzat8 Blvd, O� Water-Su I <br /> pp y Well ❑Monit.Well r <br /> Show exact location of well or boring `, of well or boring Env.Bore Hole <br /> in section grid with"X:' ng property ❑ ❑Other ft. below ❑above land surface <br /> ads,a buildings. CASINGTYPE(S) <br /> Steel ❑Plastic ❑Tile F-!Other <br /> -- '--- ------- - �� WELLHEAD COMPLETION <br /> W E T <br /> +----- ---T--- <br /> Outside: ❑Well House At Grade Inside: Basement Offset <br /> -�-- -4- <br /> 'h Mile itless Adapter/Unit L�Buried ❑Well Pit <br /> ❑P' <br /> E]Buried <br /> s r ❑Well Pit --_ <br /> .J'� ❑Other ❑Other <br /> 7845, nOi <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> MomK/1 Diameter Depth r Set in oversize hole? Annular space initially grouted? <br /> Property owners mailing address if different than well location address indicated above :z <br /> t in.from�_ to 1i e ft. ❑Yes ox No El Yes ❑No El Unknown <br /> srMBolander a Sons Company in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 251 Sark* Set1� A <br /> SPaul li� M 55107 2 of 2 in,from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> I � <br /> Well owners mailing address if different than property owner's address indicated above Screen from to ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill WNo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ElYes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not kpown,indicate estimated formation log from nearby well or boring: <br /> s Type <br /> t v <br /> ❑Removed Not Present F1 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=941bs,one bag of bentonite=50 Ibs.) <br /> Grouting material 04A romJ�_ to" ft. yards bags <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 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 /> Dan Stodola Well Drilling Co,. Inc. 1691 <br /> Contractor Business Name License or Registration No. <br /> 01.1 <br /> 7 <br /> rti depresentative Si at Certified Rep.No. Date <br /> LOCAL COPY H 261703 <br /> Name o/Person Sealing Well or Boring <br /> HE-01434-09 IC#140-0423 6/06R <br />