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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring ng No. '„I 231301 <br /> �3 1 3 0 1 <br /> County Name <br /> WELL AND BORING SEALING RECORD MinSeanesota Unique Well No. L <br /> eHenntdin Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave Inv*n not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm-s-Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 20 24-0045 .5.-' ,tom 05 <br /> GPS Latitude degrees minutes seconds / r <br /> LOCATION: Depth Before Sealing81 ft. Original Depth R <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 0 Multiaquifer <br /> L/BORING Measured ❑Estimated <br /> 2647 Rtht"1 Ave, flrnno 55191 Water Supply Well 0 Monit.Well ! <br /> Show exact location of well or boring cap of �J <br /> in section grid with"X" locatSketionhm,showingwell proor oring <br /> rty'.` 0 Env.Bore Hole ❑Other / ft. below 0 above land surface <br /> N lines,roads,and buil 9��J CASING TYPE(S) <br /> ---f-----l-----, A \t Steel0 Other <br /> 0 Plastic 0 Tile <br /> W E ,— ( WELLHEAD COMPLETION <br /> T1 1 1, Outside: ❑Well House Inside: ❑Basement Offset <br /> I f I , I 14mifs i VJ pt<Pitless Adapter/Unit 0 Well Pit <br /> S I 9, 0 Well Pit 0 Buried <br /> �—r"rs ' \I 0 Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Gordan Amundson 952-471-7700 Dia eterif Depth ! 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 t0 � f'ft. ❑Yes Jo 0 Yes D No ❑Unknown <br /> in.from to ft. 0 Yes 0 No 0 Yes 0 No 0 Unknown <br /> in.from to ft. 0 Yes 0 No ❑Yes 0 No 0 Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE t <br /> Well owner's mailing address if different than property owner's address indicated above Screen from PA to C.JLJ ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe) j,tjA i j( /1 7 ." 9-- aimp <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? )(Yes ❑ No Describe <br /> FORMATION — <br /> If not known,indicate estimated formation log from nearby well or boring PUMP ,+ Pomp//�� <br /> "i T c)___,(---,),..?, Type .�C,e 1- o m/ + <br /> ( *Removed 0 Not Present Cl Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> �/No Annular Space Exists CI Annular space grouted with tremie pipe CI 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 lbs.) <br /> y�,1� <br /> (t/ <br /> Grouting Material �" t rom�to C l . yards bags <br /> from to tt. yards _ bags <br /> _from to ft. _ yards bags <br /> fi <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 /> Don Stodola Well.Drilling Co, Inc. 27172 <br /> Contractor Business amee License or Registration No. <br /> ''duthotaed't sentafive Signature= Date <br /> \ �.. _ _�. <br /> LOCAL COPY H 231301 Name of Person Sealing Well or Boring <br />