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Minnesota <br />ll <br />WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. and Boring H 37277 <br />7 <br />County Name -WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br />Minnesota Statutes, Chapter 1031 �r W�*0W No. <br />�s <br />Orme In <br />Township Name Township No. I Range No. Section No. I Fraction (sm. - Ig.) Date Sealed Date Well or Boring Constructed <br />Orono 1 117 23 107 c*1 sF. w, p Q <br />GPS LOCATION - decimal degrees (to four decimal places) <br />Depth at Time of Sealing Q�ft. Original Depth tt. <br />Latitude Longitude <br />AQUIFER(S) STATIC WATER LEVEL <br />Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑ Multiaquifer { <br />WELL/BORING Measured Date Measured) r)h� ❑ Estimated <br />I A( Water -Supply Well El Env. Well <br />S ow exact location o(we�l or boring Sketch map of well or boring ❑Temp. Env. Well El Other ft. below <br />in section grid with "X" locati n, showing property ❑ above land surface <br />N lird�ds, and buildings. CASING TYPES) <br />-` <br />Steel E] Plastic El Tile [_1 Other <br />--- -- --- ---------- <br />WELLHEAD COMPLETION <br />W E <br />i } I T } Outside: ❑ Pliless Adapter/Unit ❑ At Grade Inside: ❑Basement Offset <br />'h Mile O LlWell Pit Buried Well House <br />❑ Well Pit <br />1 ❑ Other <br />s ❑ Buried <br />�1 Muer ❑ Other <br />For multiple temporary environmental wells, provide additional location CASING(S) <br />information, a site sketch, and geology on a separate page. Diameter r Depth / Set in oversize hole? Annular space initially grouted? <br />PROPERTY OWNER'S NAME/COMPANY NAME I I in. from_8 to dip_ ft. ❑ Yes No ❑ Yes [I No ❑ Unknown <br />P ne ' i dRVMAd1JAtrCWgddress indicated above✓ in. from to 1� ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />X16230 54th St in. from to ft. E] Yes ❑ No ❑ Yes El No El Unknown <br />St. Michael, T 55376 SCREEWOPEN HOLE ` <br />WELL OWNER'S NAME/COMPANY NAME WELL <br />from-50 to 43(/ it. Open Hole from to ft. <br />OBSTRUCTIONS <br />Well owner's mailing address if different than property owner's address indicated above Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />r 7-` <br />Type of Obstructions (Describel til A"- n '-/6r <br />Obstructions removed? es ❑ No Describe <br />'i PUMP <br />GEOLOGICAL MATERIAL I COLOR HFORMATIONR FROM TO 1 1 4 Not Present ❑ Present, Removed Prior to Sealing ❑ Other <br />If not known, indicate estimated formation log from nearby well or boring. Type <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 />sing Diameter <br />In. from to ft. [J Perforated ❑ Removed <br />in. from to ft. E]Perforated ❑ Removed <br />Type of Perforator <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes OK <br />No TWl <br />GROUTING MATERIAL(S) (One bag of cement = 94 lbs., one bag of bentonite = 50 lbs.) <br />f� <br />Grouting Material a from to ft. yards bags <br />from to ft. yards bags <br />from to ft. yards bags <br />OTHER WELLS AND BORINGS <br />Other unsealed and unused well or boring on property? ❑ Yes No How many? <br />LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING 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 />Licensee Business Name License or Registration No. <br />3-10-20 <br />Ile <br />epresenta ' gn e \ Certified Rep. No. Date <br />{, 7 'Jim Antonson <br />LOCAL COPY JH 3 7 2 7 i! 1 Name of Person Sealing Well or Boring <br />HE -01434-16 ID# 53159 9/178 <br />1 <br />