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<br /> MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H —ski2 1 0 1
<br /> WELL OR BORING LOCATION Sealing No.
<br /> WELL AND BORING SEALING RECORD
<br /> County Name Minnesota Unique Well No.
<br /> Minnesota Statutes,Chapter 1031 or W-series No. CEIVr"
<br /> Township Name Township No. Range No. Section No. Fraction(sm.-)Ig.) Date Sealed Date Well or Boring Constructed I U
<br /> 117 2 $ 2ol,i L. ,,:'Af. ."1,,4 'A
<br /> O
<br /> CITY F On.DNO
<br /> GPS LOCATION-decimal degrees(to four decimal places) 1
<br /> Depth at Time of Sealing 2Ce) ft. Original Depth ft.
<br /> Latitude Longitude
<br /> AQUIFER(S) STATIC WATER LEVEL
<br /> .-
<br /> Numerical Street Address or Fire Number and City of Well or Boring Location y_l Single Aquifer 0 Multiaquifer
<br /> WELLJBORING Measured Date Measured -,...g rnA- 14N"Y E Estimated
<br /> ..,L.io Dunwoody Ave Orono, fi-, -ii,.....,lc.1
<br /> li - -VrWater-Supply Well 0 Monit.Well
<br /> .., ,.../
<br /> Show exact location of welt or boring
<br /> in section grid with"X." lSokceatt?ohnmsat%owfi showing
<br /> Iroorp*g ,—.
<br /> L j Env.Bore Hole E Other (..,114‘.1 ft. )114below 0 above land surface
<br /> '
<br /> N : ads,and buildit ,;., /.
<br /> CASING TYPE(S)
<br /> ----:,------:,- i-
<br /> .
<br /> Steel 0 Plastic 0 Tile 0 Other
<br /> WELLHEAD COMPLETION .
<br /> ,. .
<br /> w
<br /> r E —,.
<br /> T __. 5. )2
<br /> 7" OutsideX 01 Pitless Adapter/Unit At Grade Inside: E Basement Offset
<br /> 'h Mile ,4 ' -;,i D Well Pit 0 Buried 0 Well House
<br /> . , .
<br /> --- -_,_ ,. t1 * i
<br /> \,,, 0 Well Pit
<br /> ) 1 0 Other
<br /> S '---...-: .......1/ /Th . 0 Buried
<br /> 1-----1miln-----1 ____—.--"- 0 Other
<br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
<br /> -•Ce •Li‘..-i.1- ,../ Diem _
<br /> d.,/ Depth f Set in oversize hole? Annular space initially grouted?
<br /> Property owner's mailing address if different than well location address indicated above ii 1 in.from 1J to /96 ft.
<br /> 0 Yes X No 0 Yes E No LI Unknown
<br /> in.from to ft. 0 Yes 0 No 0 Yes E No LI Unknown
<br /> in.from to ft. E Yes 0 No 0 Yes 0 No 0 Unknown
<br /> //.
<br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
<br /> I
<br /> Screen from /WO t2e...6 ft. Open Hole from to ft. ' 4,Well owner's mailing address it different than property owner's address indicated above
<br /> OBSTRUCTIONS
<br /> 0 Rods/Drop Pipe D Check Valve(s) 0 Debris 0 Fill XNo Obstruction
<br /> '. .
<br /> Type of Obstructions(Describe) ,
<br /> GEOLOGICAL MATERIAL COLOR 112,DZE,71,7 FROM TO Obstructions removed? E Yes 0 No Describe ..
<br /> . _
<br /> If not known,indicate estimated formation log from nearby well or boring. PUMP
<br /> ' 'Not Present /Present,Removed Prior to Sealing El Other
<br /> ,4 AI
<br /> A Type
<br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
<br /> XNo Annular Space Exists 0 Annular Space Grouted with Tremie Pipe 0 Casing Perforation/Removal
<br /> Casing Diameter
<br /> in.from to ft. 0 Perforated 0 Removed
<br /> in.from to ft. 0 Perforated 0 Removed
<br /> Type of Perforator
<br /> VARIANCE
<br /> Was a variance granted from the MDH for this well? 0 Yes No TN# . -• -
<br /> GROUTING MATERIAL(S) (One bag of cement- 4 lbs.,one bag of bentonite=50 lbs.) ,./.
<br /> _ 1
<br /> .. o
<br /> Grouting Materia from__________to 240 ft. yards/en bags
<br /> .;.
<br /> from to ft. yards bags
<br /> ...-. i
<br /> from to ft. yards bags i
<br /> i•
<br /> OTHER WELLS AND BORINGS
<br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? 0 Yes X'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. 1 ').1. --...-.
<br /> . Licensee Business Name License or Registration No.
<br /> 558 A')- - 1 7 •,
<br /> •
<br /> Ci-- reenla-live?Signature Certified Rep.No. Date
<br /> ...,—
<br /> - ,
<br /> , ...,
<br />. , LOCAL COPY H 3 5 2 1 0 1. tv • 1....0; -,----,
<br /> Name of Person Sealing Well or Boring ;74---V-Y.--- '' • -1.. ' -- •
<br /> HE-01434-15 ID#53159 8/169,'
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