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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 81 4 9 2
<br /> WELL AND BORING SEALING RECORD
<br /> County Name MinnlesotaoUnique Well No.
<br /> Minnesota Statutes,chapter 1031 or W serieskN o.
<br /> (Lve blank II notJ1 nnopfr
<br /> Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed
<br /> Ornnc3 117 73 17 0.—§W ' /01 .2/ -- t''
<br /> GPS LOCATION-decimal degrees(to four decimal places) /
<br /> Depth at Time of Sealing f 43L ft. Original Depth _ ft.
<br /> Latitude Longitude
<br /> �A-Q{UIFER(S) STATIC WATER LEVEL
<br /> Numerical Street Address or ire Number and City of Well or Boring Location Lr Single Aquifer ❑Multiaquifer j J )�
<br /> WELL/BORING ,Measured Date Measured i J Oz ❑Estimated
<br /> 3520 Livingston-Ave* Orono 0 Water-Supply Well ❑Env.Well. • '
<br /> Show exact location of well or boring ' Sketch map of well or boring ,--, ���/// '
<br /> in section grid with"X" location,showing property ❑Temp.Boring EI Other - '7 ' ft. Ly below ❑above land surface
<br /> N lines,roads,and buildings. CASINGTYPE(S) f •
<br /> *----] Steel El Plastic Li ❑Other
<br /> --- '-- '-- --------- WELLHEAD COMPLETION •
<br /> w E '�
<br /> T
<br /> Outside:'❑Pitless Adapter/Unit ❑At Grade Inside: Basement Offset
<br /> Mile ❑Well Pit ❑Buried WellHouse
<br /> r 1
<br /> ❑Other ❑Well Pit
<br /> . S ❑Buried
<br /> I • 1 Mile —I 4,::,) ,
<br /> /�( ❑other
<br /> For temporary borings,provide additidithl lbc`ation 4-,
<br /> VaCASING(S)
<br /> information,a site sketch,anmet
<br /> d geology on a separate pe. Dialer Depth Set in oversize hole? Annular space initially grouted?
<br /> 1 /
<br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from `� to /Ii
<br /> e7 ft. ❑Yes 'INo ❑Yes ❑No ❑Unknown
<br /> Trin T*wisstu is TTI!
<br /> Property
<br /> owner's mailing address if �V2t
<br /> different than well location address indicated above in.from to ft. ❑Yes ❑No El Yes Yes No ❑Unknown
<br /> 34 13th Ave NE, Ste 80in.from to ft. ❑Yes ❑No ❑Yes ❑No
<br /> 'j ❑Unknown
<br /> Minneapolis, Iti 55413 SCREEWOPEN HOLE '
<br /> WELL OWNER'S NAME/COMPANY NAME Screen from / f/0 to *C)` ft. 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 El Fill ❑No Obstruction
<br /> T 11 `
<br /> Type of Obstructions(Describe) Kt-a, , -C.--_-_, -.5,--
<br /> Obstructions removed? 'Wes ❑No Describe
<br /> PUMP
<br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present , [ 'resent,Removed Prior to Sealing❑ ❑Other
<br /> If not nown,indicate estimated formation log from nearby well or boring. Type -"h. 9_k
<br /> /A--' 0 (, 1,8,1 METHOD USED TO kAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
<br /> [ Vo Annular Space Exists ElAnnular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal
<br /> f asing Diameter
<br /> i in.from to ft. ❑Perforated ❑Removed
<br /> in.from_ to ft. ❑Perforated ❑Removed
<br /> Type of Perforator
<br /> VARIANCE ,�f'
<br /> Was a variance granted from the MDH for this well? ❑Yes [?No TN#
<br /> -GROUTING MATERIAL(S) _./. s / '7
<br /> Grouting Material /1)'1 i it.. (;) ; o fLm ("s to f,":;.*1 ft. yards_ bags
<br /> 9
<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 T
<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 /> Don. Stodola Well Drilling Co,, inc. 1691
<br /> Licensee Business Name
<br /> f"-...-7,74-7-7"-"
<br /> License or Registration No.
<br /> `_,..,1/7„' '.�C �i- / j4. ! al" '- fes,
<br /> Ce _ed fiepfesentative Signetur "' ' Certified Rep.No. Date j
<br /> p
<br /> LOCAL COPY H 3 8 1 4 9 2 .., ,. .
<br /> -,.. .)..f,,,,,,A / (:-0,,,,.._,
<br /> ', ", ,-.'
<br /> Name of Person Sealing Well or Boring /
<br /> HE-01434-17 ID#53159 11/19R
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