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Q <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 1 8 6 4 0 <br /> Sealin <br /> County Name WELL AND BORING SEALING RECORD MinnesotaoUnique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Hennepin yea edkAnotkn <br /> anmxn) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 04 S St IN 11 -17- 1 y <br /> GPS LOCATION—decimal degrees(to four decimal places) ;/ <br /> Depth Before Sealing I ) ! _ft. Original Depth ft. <br /> Latitude Longitude <br /> A UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring/� Location Lingle Aquifer LIMultiaquifer ,„,i-I r� <br /> 225 Old Crystal Bay Rd S. Orono ELL/BORING Measured 111 Estimated Date Measured <br /> Water-Supply Well 10 Monit.Well <br /> Show exact location of well or boring Sketch map of well or bori <br /> in section grid with"X." location,showing propel ❑Env.Bore Hole ❑Other 7P ft. 1 below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> 3Steel ❑Plastic ❑Tile ❑Other <br /> '--'---'--'------`--'-----' //��•^'--R /\ ELLHEADSteelCOMPLETION <br /> w : E <br /> T l� -'/ Outside: ❑Well House ❑At Grade Inside: [Basement Offset <br /> ifyMile <br /> HI ❑Pitless Adapter/Unit ❑Buried 111 Well Pit <br /> r R <br /> II]Buried <br /> S ❑Well Pit <br /> ['Other <br /> I I Mile----I --' ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAMI° CASING(S) <br /> Norman/Angela Hay Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address indicated above -3 ii I 0 El Yes [ No ❑Yes El No ❑Unknown <br /> Sionnet from to ft. <br /> 44 Chemin de Sionnet in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 1254 Jussy <br /> Switzerland 1254 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE�I <br /> Well owner's mailing address if different than property owner's address indicated above Screen from ' V to r2ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> (ji Rods/Drop Pipe ❑Check Valve(s) ❑Debris` El Fill ❑No Obstruction <br /> Type of Obstructions(Describe) �rO /•!"f VW y43 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? 1 Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not known,indicate estimated formation log from nearby well or boring. r�! v.-, r { <br /> Type J <br /> a f, <br /> NRemoved ❑Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> j No 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 /> I <br /> Type of Perforator <br /> VARIANCE <br /> RECEIVEDWas a variance granted from the MDH for this well? ❑Yes If No TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> MAY 2 3 20141 1 <br /> Grouting Material 4t ( <<^k -v+- from C to 17 7 ft. yards 6 bags <br /> Ci„ OF ORONO 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 II o 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 f , TNC. 1691 <br /> Licensee Business Nam License or Registration No. <br /> .. <br /> � <br /> -6-6. <br /> ,;: �►'� . 558 /--,:?/-/y <br /> Ce .e pr entative Signature • Certified Rep.No. Date <br /> LOCAL COPY H 31$640 " ` ' <br /> Name of Person Sealing Well or Boring <br /> HE-01434-14 IC#140-0423 5/13R <br />