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Minnesota <br /> WELL OR,BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. <br /> and Boring 3 5 5 5 5 4 <br /> Coultty Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or w e erier No. <br /> Hennepin <br /> Township Name Township No. Range No. Section No. Fraction(sm.-n Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 N` SL NE 9 1/7/i9 . <br /> GPS LOCATION-decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 951 ft. Original Depth ft. <br /> Latitude Longitude <br /> OUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location (Single Aquifer Multiaquifer ^ <br /> 1151 North Arm nr, Orono 55364 C WELL/BORING - 'Measured Date Measured SA/YV / i*" ❑Estimated <br /> s Water-Supply Well ❑Monit.Well e <br /> Show exact location of well or boring Sketch map of well or. rl,• /-� <br /> in section grid with"X" location,showing grope y Env.Bore Hole ❑Other -/5 ft. Ybelow ❑above land surface <br /> lines,roads,and¢rgldi s <br /> N CASING TYPE(S) <br /> •,2 (rrt; Steel Li]Plastic ❑Tile ❑Other <br /> --'-----'------`--•------ WELLHEAD COMPLETION <br /> W E <br /> ---i__-,---r--,__-;_-__--_-• Outside:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile LIWell Pit ❑Buried ❑Well House <br /> ❑Well Pit <br /> ❑Other <br /> 9 - I ❑Buried <br /> - <br /> � t Mile-� <br /> ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Paul VO Strom Diameter / Depth Set in oversize hole? Annular space initially grouted? <br /> Property owners mailing address if different than well location address indicated above y ,in.from Q to 90 ft. ID Yes *No ❑Yes ❑No ❑Unknown <br /> 10231 Beebe Lake Rd in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Hanover, MN 55341 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> • <br /> Well owner's mailing address if different than properly owner's address indicated above Screen from l�' to �� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill Ago Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not;tcnown,indicate estimated formation log from nearby well or boring. <br /> Wot Present ❑Present,Removed Prior to Sealing ❑Other <br /> d A i 0 ->y Type <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> (l Callo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> sing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? ❑Yeso TN# <br /> GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) <br /> • <br /> Grouting Materialp,L�CA G/UI from d to q 14 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? ❑Yeslo 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 /> Don Stodola Well Drilling Co., Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> ' <br /> `/ ii_� /� <br /> 2ntaiveSighature Certified Rep.No. Date <br /> LOCAL COPY H . i r. / �// jtd Q,SY•�� <br /> 3 5 5 55 4 Name of Person Sealing We or Boring <br /> HE-01434-15 Da 53159 k, 9/1611 <br />