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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring WELL OR BORING LOCATIONSealing oH 3699d, r 2 County Name WELL AND BORING SEALING RECORD Minnesota Unique Minnesota Statutes, Chapter 1031 or W -series No. (U— ea* a W w--) rT _ tot xi-"- a' Township No. Range No. Section No. Fraction (sm. Ig.) Date Sealed Date Well or Boring Constructed d d u T ATION - decimal agrees (to tour 2ecimai places) Depth at Time of Sealing Original Original Depth ft. Latitude Longitude AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Mulllaquifer 420 Lakeview Parkway, Orono WELUBORING >0 Measured Date Measured '7.4 MA Estimated Water -Supply Well ❑ Env. Well ♦ Show exact location of well or boring Sketch map of well or boring in section grid with "X.° 3 location, showing property ❑ Temp. Env. Well ❑ Other below [-]above land surface N% lines, roads, and buildings. CASINGTYPE(S) r Steel ❑ Plastic ❑ Tile ❑ Other i -- - -- ---t-- J WELLHEAD COMPLETION W E Outsider Pitless Adapter/Unit ❑ At Grade Inside: ❑Basement Offset h Mile $Well Pit ❑Buried ❑ ❑ We House Well Pit F-1 Other s ? Y �1 Mitek r;� For multiple temporaryenvironmental wells, information, a site sketch, and geology on a 11r rovide additional location eparate page. ❑ Burled ❑ Other CASING(S) Diameter� ♦ Depth ♦ Set in oversize hole? Annular space initially grouted? � in. from_ _ to, 1__ ft. Elrs)t Yes No ❑ Yes ❑ No ❑ Unknown in. from to ft. El Yes El No ❑ Yes No ❑ Unknown in. from to ft. ElYes ElNo ❑ Yes ❑ No E]Unknown PROPERTY OWNER'S NAMEICOMPANY NAME AT TT ri§ Pr ol's ma Gress if different than well location address indicated above 1�2J11. c titJ 45thAve N,� GSte r Plymouth, MW 5944& SCREEWOPEN HOLE Screen from to ft. Open Hole from to 29 ft. WELL OWNER'S NAME/COMPANY NAME OBSTRUCTIONS ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill No Obstruction Type of Obstructions (Describe) Obstructions removed? ❑ Yes ❑ No Describe Well owner's mailing address if different than property owner's address indicated above PUMP Not Present Present, Removed Prior to Sealing ❑ g ❑ Other Type GEOLOGICAL MATERIAL COLOR HARDNESS OR FORMATION FROM TO If not known, indicate estimated formation log from nearby well or boring. .` l I METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BOREHOLE No Annular Space Exists ❑ Annular Space Grouted with Tremae Pipe ❑ Casing Perforation/Removal Casing Diameter in. from to ft. ❑ Perforated ❑ Removed in. from to ft. ❑ Perforated ❑ Removed Type of Perforator / .lf s + • VARIANCE Was a variance granted from the MDH for this well? ❑ Yes XNo TN# GROUTING MATERIAL(S) (One bag of cement = 04 His., one bag of bentonite = 50 lbs.) — , / p r Grouting Material/,/4,q aIYXL)/ from c/to .7-17 R. yards bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑ Yes XNo How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION This well or boring was sealed in accordance with Minnesota Rules, Chapter 4725. The information contained in this report is true to the best of my knowledge. Don Stodola Well Drilling Co,. Inc. 16% REMARKS, S gE DF�OATA, DIFFICULTIES IN SEALING .,_..,. .. APRQ 3 2020 CITY OF O RO �o Licensee Business Name License or Registration No. ied R6presen ali6e Signature Certified Rep. No. Date , r' LOCAL COPY H 6 �" 1." 0 `-C 2 Name of Person Sealing Well or Boring HE -01434-16 ID# 53159 an 7R