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WELL OR BORING LOCATION r MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring " { �)(1 `� <br /> County Name <br /> WELL AND BORING SEALING RECORD Sealies°a°unique well No. <br /> L G�J <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave dank if not known) <br /> Township Name Township No. Range No. Section No. Frig (sm.-Ig J Date Sealed Date Well or Boring Constructed <br /> Orono 117 211 07 '1�[I I / /4MrA l <br /> GPS Latitude degrees_ minutes seconds Depth Before Sealing ft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> A�OUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location 79 Single Aquifer ❑Multiaquifer A <br /> W LL/BORING Measured ❑Estimated Date Measured °xPYi`-' r-V-�/6j <br /> 4731 North Shore DC Orono Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X" location,showing property ❑Env.Bore Hole ❑Other Ak4AL tt. Vbelow ❑above land surface <br /> I' es,ro sand buildings. <br /> N f, CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> --'I----- '--`-----`-- WELLHEAD COMPLETION <br /> W E T r <br /> Outside: L1 Well Nouse XAt Grade Inside: Ll Basement Offset <br /> h Mile •, <br /> ❑P'Itless Adapter/Unit ElBuried El Well Pit <br /> LVID <br /> Buried <br /> s ❑Well Pit <br /> El Other <br /> �1 Mile -I -.+'.4-�..r.. /t,:t- yl-`^a-•. rx F-1Other -- --- <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Col son nigmirl Timpn Diameter Depth <br /> G; , Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above Z'of in.from Q t0 56 ft. ❑Yes XNo ❑Yes ❑No ❑Unknown <br /> 216 Water St in.from ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Excelsior, MN 55331 <br /> n.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> � 1 <br /> Well owner's mailing address if different than property owner's address indicated above Screen from r� to 4.� ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill X No Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL I COLOR HARDNESS <br /> oOR FROM TO Obstructions removed? El Yes El No Describe <br /> FORM <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> Type <br /> ❑Removed XNot Present ❑Other <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 /> in.from to ft. ❑Perforated ❑Removed <br /> in.from to ft. ❑Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=501bs.) <br /> Grouting Material&Q7 Cee^5,4.T from U to &0 ft. yards Z 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 %. How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION I <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 /> Dw Stodola Well drilling Co. Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> 4-19-13 <br /> erh d Frepresentatilve Sighatt re Certified Rep.No. Date <br /> " 312 017 Jim Monson <br /> LOCAL COPY Name of Person Sealing Well or Boring <br /> HE-01434-13 IC#140-0423 5/128 <br />