05/06/2020 - well and boring sealing record

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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Well and Boring Sealing No. H 3 7 5 4 6 5 County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes,Chapter 1031 or W-series No. (Leave blank Inot known) T aNpin Township me Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed _nrono 117 23 06 I 10 S4 -.... _f,, ' --) GPS LOCATION-decimal degrees(to four decimal places) // .- Depth at Time of Sealing 1'r%-Li ft. Original Depth ft. Latitude Longitude AQUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location x( Single Aquifer ❑Multiaquifer r WELL/BORING >e Measured Date Measured _. - �-' - - ❑Estimated 420 Lakeview Parkway, Orono Water-Supply Well ❑Env.Well J Show exact location of well or boring Sketch map of well or boring El Temp.Env.Well ❑Other ! ti ft. elow ❑above land surface in section grid with"X" location,showing property II Utes,roads,and buildings. CASING TYPE(S) Steel ❑Plastic ❑Tile ❑Other ---'--- --`------ --- ',`J v..,''''°'°- `')-k - WELLHEAD COMPLETION w ET Outside: Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset �'+i 'h Mile , I '�`t ❑❑Well Pit ❑Buried Well House -----_, -- - - ❑Well Pit Other s ❑Buried I 1 Mile ❑Other For multiple temporary environmental wells,provide additional location CASING(S) information,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted? PROPERTY OWNER'S NAME/COMPANY NAME qin.from to IC / ft. El Yes ,No El Yes El No ❑Unknown MortrTWIa. Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown 18215 445th Ave N, Ste D in.from to ft. ❑Yes ❑No ❑Yes ❑No EI Unknown Plymouth, MN 55446 SCREEWOPEN HOLE Screen from /6 / to to-Z: ft. Open Hole from to ft. WELL OWNER'S NAME/COMPANY NAME OBSTRUCTIONS Well owner's mailing address if different than property owner's address indicated above 'Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction Type of Obstructions(Describe) % ,_.._ Obstructions removed? 'j Yes ❑No Describe PUMP GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO resenresen,Removedto Sealing FORMATION ❑NotPresent '�Present, PriorSli ❑Other If not known,indicate estimated formation log from nearby well or boring. �. ._, 0 --.-. f-_..A.--°--.-- Type s - st /,7�METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE KK J C l I No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal r /Casing Diameter // in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed Type of Perforator VARIANCE Was a variance granted from the MDH for this well? ❑Yes No TN# GROUTING MATERIAL(S) (One bag off-cement=94 lbs.,one bag of bentonite=50 lbs.) Grouting Materia' (lr• from '1 to rJ ft. 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?No How many? _ LICENSED OR REGISTERED CONTRACTOR CERTIFICATION 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 is true to the best of my knowledge. Don Stodola Well Drilling Co., Inc. 1691 Licensee Business N me License or Registration No. ' : - C .ed14 presentative St : re • Certified Rep.No. Date H 375465 ,• a LOCAL COPY ~ F t6 4 n"� Name of Person Sealing Welt or Boring / HE-01434-16 ID#53159 1 i 9117E