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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H <br /> WELL AND BORING SEALING RECORD Sealing No. 3 5 21. 2 <br /> County Name Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> P (Leave Wank H not known) <br /> nennAPin <br /> Township Narlhe Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed <br /> -nronn 11fl 73 36 p Titr. 4 : 92`7//7 <br /> GPS LOCATION- decimal degrees(to four decimal places) / <br /> Depth at Time of Sealing / ft. Original Depth ft. <br /> Latitude Longitude <br /> IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location mingle Aquifer ❑Multiaquifer cn� <br /> WELL/BORING Measured Date Measured J/")//!� J I/7/ ❑Estimated <br /> 111 Chevy Chase Dr, Orono 55391 r- XWater-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well o(bon g Q <br /> in section grid with"X" location,showing grope ❑Env.Bore Hole ❑Other T� ft.A below ❑above land surface <br /> lines,roads,and b din <br /> > t c-' Steel ❑Plastic ❑Tile ❑Other <br /> " " <br /> -''-""' ''-''--""-- ET J 1----_ WELLHEAD COMPLETION <br /> W Q <br /> -' <br /> ,---•--,------r------ I <br /> r--------'0) <br /> '�''`�� Outside: El Pitless Adapter/Unit ❑At Grade Inside: Basement Offset <br /> 'h Mile -.- 1 ❑Well Pit ❑Buried ❑Well House <br /> 1 ' r ❑Other ❑Well Pit <br /> s i_____ <br /> _ _ _ __ ❑Buried <br /> I i Mile y <br /> ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> harllc ('l r�. Diameter t Depth Set in oversize hole? Annular space initially grouted? <br /> Property o er's ma((ng a ress if different than well location address indicated above <br /> 4..... ."+t in.from to 13'� ft. ❑Yes o ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN�H�OLLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from��j/ to !Y3 r ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> NIXT Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) � �� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? XYes ❑No Describe RECEIVED <br /> FORMATION <br /> If not nown,indicate estimated formation log from nearby well or boring. PUMP <br /> �- ❑Not Present /X Present,Removed Prior to Sealing ❑Other NOV U ? LU I, <br /> O /7.�Type T&T Pump <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING ANI ANOPPrialgORONO <br /> o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> asing Diameter <br /> in.from to ft. ❑Perforated 111 Removed <br /> • <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> VARIANCE !' <br /> Was a variance granted from the MDH for this well? ❑Yes ' No TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> / <br /> Grouting Material N�/97.64/ Vugfrom 4, to"b3 ft. yards bags <br /> w' <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> ; <br /> OTHER WELLS AND BORINGS / <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes 1fL!�No 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 <br /> is true to the best of my knowledge. <br /> Don Stodola Well Drilling co,Inc, 1691 <br /> Licensee Business Name License or Registration No. <br /> fiet!Re resentative a ure Certified Rep.No. Date <br /> LOCAL COPY H 3 21 A o yrrY Y-\. <br /> L '7 Name of Person Sealing Well or(>BoringY <br /> HE-01434-15 ID#53159 I• 8116R <br />