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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H <br /> County Name WELL AND BORING SEALING RECORD Minnesota <br /> No. <br /> Sealing <br /> Minnesota Unique Well No. <br /> -251769 <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> !�. - (Leave Blank n-known) <br /> Township Name Township No. Range No. Section No. Fraction(sm i Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 1.17 23 03 32-M12"_ // �t ✓(� <br /> GPS Latitude degrees minutes seconds , <br /> LOCATION: Depth Before Sealing �-�`4/ ft. Original Depth ft. <br /> Longitude degrees minutes seconds QUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> = WELUBORING Measured E] Estimated <br /> 14 50 {y Water Supply Well ❑Monit.Well f <br /> Show exact location of well or boring Sketch map of well or boring , t7 <br /> t <br /> in section grid with"X" �' location,showing property E]Env.Bore Hole E]Other 7 ft. pelow ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> ----- <br /> (71 <br /> 74 Steel ❑Plastic ❑Tile ❑Other <br /> W -�- -i-- -i-- --i-- E } WELLHEAD COMPLETION <br /> Outside: ❑Well House Inside: Basement Offset <br /> ❑Pitless Adapter/Unit ❑Well Pit <br /> -- - -i-- -i-- --�-- 't <br /> ❑Well Pit ❑Buried <br /> ❑Buried <br /> PROPERTY OWNER'SSrNAME/COMPANY NAME CASING(S) <br /> Susan ValAnt ine Diame e�i r Depth i Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above ,[ <br /> in.from to ft ft. ❑YesFlo ❑Yes E]No E] Unknown <br /> 12W Orchard Rd n ,\ <br /> 14innetonT a, � 55305 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from t0 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�t0- L. ft. Open Hole from t0 ft. <br /> OBSTRUCTIONS <br /> ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ;KNo Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? E]Yes ❑ NO Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> Type <br /> ❑ Removed X,of Present ❑Other <br /> J <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 lbs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material A241'7 from to `-L' 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 KNO 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 is <br /> true to the best of my knowledge. <br /> F1on Stodola Well Drilling Co,. Inc. 1691 <br /> Contractor Busine Name License or Registration No. <br /> J, / <br /> t ri j epresentative Sig ature' Date <br /> LOCAL COPY � H251769 , <br /> Name of Person Sealing Well or Boring <br />