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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringSealo. H <br /> 215053 <br /> County Name <br /> WELL AND BORING SEALING RECORD Minnlessong tta Unique Well No. <br /> in Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave blank,f-known) <br /> Township Name Township No. Range No. Section No. Fraction(sm�Ig) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 07 32-0020 <br /> GPS Latitude degrees minutes seconds Of <br /> / <br /> LOCATION: Depth Before Sealing `� ft. Original Depth / ft. <br /> Longitude degrees minutes seconds AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ingle Aquifer ❑Multiaquifer <br /> L q !T t+ WEELLUBORING )(Measured ❑ Estimated <br /> 47 3 1� Shor , Orono [Water Supply Well ❑ Monit.Well ` <br /> Show exact location of well or boring Sketch map of well or boring Ire <br /> in section grid with"X" <br /> Env,Bore Hofe Other ft. (Xelow above land surface <br /> ,',cation,sho roperty E] Env ❑ <br /> N `limos,rod-ad' n b ngs. <br /> /1V CASING TYPE(S) <br /> Xteel ❑Plastic ❑Tile ❑Other <br /> W -- - - -- -i-- -- -- E WELLHEAD COMPLETION <br /> r , L-- <br /> , Outside: ❑Well House Inside: E]Basement Offset <br /> km's N ]SPitlessAdapter/Unit ❑Well Pit <br /> ❑Well Pit El Buried <br /> S <br /> mAe - ` ❑Buried <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Bob Pieper Diameter Depth r Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above If <br /> in.from to ft. Yes LINO ❑Yes ❑ No ❑ Unknown <br /> 3 of 3 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 /> r <br /> Well owner's mailing address if different than property owner's address indicated above Screen from_ /6n to ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ods/Drop Pipe ❑ Check Valve(s) ❑ Debris j�❑ Fill E] No Obstruction <br /> Type of Obstructions(Describe) ��1,1% �/'9 4- i <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes El No Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring — PUMP <br /> Type <br /> ❑ Removed [ Not Present ❑ Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> )/No Annular Space Exists El Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> f 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 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material /v+'` [ IZK& rnm__ tol�L.L ft. yards 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 is <br /> true to the best of my knowledge. <br /> Don Stodola Well Drilling; Co., Inc. 27172 <br /> Contractor Business Name License or Registration No. <br /> ;eK4�� 11-19-03 <br /> uth ize epresentative S ure Date <br /> LOCAL COPY H 215 0 5 3Jim Anton <br /> Name of Person Sealing Well or Boring <br />