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s <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H No. ,�5 2 O V 1 <br /> CountyName WELL AND BORING SEALING RECORD MinnesotaSealie <br /> Unique Well No. <br /> Minnesota Statutes,Chapter 1031 oeW,lank nim i /4/t7' ;1 S.6 <br /> Rennean <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 13 97 OF g f q//7 / 1 ?- /1"77 <br /> GPS LOCATION-decimal degrees(to four decimal places) i <br /> Depth at Time of Sealing /i/e' ft. Original Depth 96 CP ft. <br /> Latitude Longitude <br /> RUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> Forest <br /> Lane, <br /> C W L/BORING Measured Date Measured 'SA/M. 1A r ❑Estimated <br /> 920 Arms La e, Orono 536 Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boringit <br /> in section rid with"X" 6 location,showing Env.Bore Hole r <br /> 9 g property ❑ ❑Other ip„7 ft. below ❑above land surface <br /> tJ �nes,roads,and buildings. <br /> ^ CASING TYPE(S) <br /> w - {{{ <br /> 1.._..{�. Steel ❑Plastic ❑Tile ❑Other <br /> WELLHEAD COMPLETION <br /> w E 1 <br /> I Outside:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile ❑Well Pit ❑Buried 0 Well House <br /> _;.__.__r_ 'I 1 <br /> ❑Other ❑Well Pit <br /> Bur <br /> I---1 Mile---I ❑Other <br /> ❑Other <br /> PROPERTYl!��.. OWNER'S NAME/C0 Y NAME CASING(S) <br /> Roger $' !Tins Diam tura ! Depth Set in oversize hole? Annular space initially grouted? <br /> Property owners mailing address if different than well location address indicated above in.from Q to 92. ft. ❑Yes lo. ❑Yes ❑No ❑Unknown <br /> same ' <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 HOLE <br /> s d s <br /> Well owners mailing address if different than property owner's address indicated above Screen from 12. to 7 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill XNo Obstruction <br /> Type of Obstructions(Describe) <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 <br /> Not Present ❑Present,Removed Prior to Sealing ❑Other <br /> �i 4 Type <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> XNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> Casing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <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 /> ' r <br /> Grouting MateriaIT�t�< from Q to 76 <br /> ft. yards e bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes 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 /> ...-- � � /1- /5 / 1 <br /> C presentative gnaTure Certified Rep.No. Date <br /> LOCAL COPY H 3 5 2 081. v= . ..y <br /> Name of Person Sealing ll or Boring <br /> t <br /> HE-01434-15 IDS/53159 <br /> 8/16R <br />