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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH MinnesotaSealieg NWell and 9gring H 3 9 1. <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. 5 5 9 <br /> Minnesota Statutes,Chapter 1031 orB W s eries No. <br /> Township N men Township No. Range No. Section No. Fraction(sm.—.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 17 SiE gE §67 8/29 //6 <br /> GPS LOCATION—decimal degrees(to four decimal places) # <br /> Latitude Longitude Depth at Time of Sealing 2# ft. Original Depth ft. <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number andmeCity of Well or Boring Location Single Aquifer ❑Multiaquifer i� <br /> 3635 Togo Rd, Orono 55391 ELL/BORING INtMeasured Date Measured 514/71C /A ❑Estimated <br /> Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or boring 1 <br /> in section grid with"X." location,showing property ❑Temp.Env.Well ❑Other /, ft. Xbelow ❑above land surface <br /> Nnes,gand ings. CASING TYPE(S) <br /> ❑Steel ❑Plastic ❑Tile XOther - • a I, <br /> ---'----- ---`-----f--- T WELLHEAD COMPLETION <br /> w EI <br /> ________________r Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile 1....... ..=.),i <br /> [1]Well Pit ❑Buried ❑Well House <br /> -------- ---- ---- -- 1 <br /> ❑Well Pit <br /> s ❑Other <br /> ❑Buried <br /> I1 Mile-----1 ! <br /> yrOther <br /> For multiple temporary environmental wens,pro ide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter Depth ' Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME din.from_aL to_al_1 ft. ❑Yes >INo ❑Yes ❑No ❑Unknown <br /> !Vivid &eablfb <br /> Property owner's mailing address/ if different than well location address indicated above in.from to ft. El Yes ❑No ❑Yes ❑No ❑Unknown <br /> 227Ridge in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Golden Valley, TIN 55422 SCREEN/OPEN HOLE <br /> WELL OWNER'S NAME/COMPANY NAME Screen from to ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe)..4hpA.€ den -' } F tt/R<✓� <br /> Obstructions removed? .Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present XPresent,Removed Prior to Sealing ❑Other <br /> If not sown,indicate estimated formation log from nearby well or boring. Type <br /> Al I.J t METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CAS GS,OR CASING AND BORE HOLE <br /> ���LL..JJJ 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 o TN# <br /> GROUTING MATERIAL(S) (One bag of cement=9 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Materia 4 7 OS06//jr from_ to ft. yards_3r,_ bags <br /> - from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes XNo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 /> _ 8- 30_ / ya <br /> di=- -e.� .five Sig ature Certified Rep.No. Date <br /> LOCAL COPY " 3 5 9 .15 9 Name of Person Sealing Well or §ring ik ` ANN <br /> �'sY-NJ <br /> HE-01434-16 ID#53159 I91178 <br />