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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 113025 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. <br /> County Name Minnesota Unique No. <br /> p�i'•'(� Minnesota Statutes,Chapter 1031 or W-series No. <br /> H�Y (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.->Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 17 31-<)034, G 9� <br /> Numerical Street Address or Fire Number and City of Well or Boring Location <br /> 3545 Togo Rd, Orono 55391 Depth Before Sealing Z ft. Original Depth r ft. <br /> Show exact location of well or boring Sketch map of well or boring AQUIFER(S) STATIC WATER LEVEL <br /> in section grid with"X". -- location, show}ne property Sin le Aquifer <br /> ;i Iin6lii�s(�r1i buildings g q E] Multiaquifer <br /> N WELUBORING Measured ❑ Estimated <br /> i <br /> ater Supply Well ❑Mont.Well <br /> ❑ Env.Bore Hole ❑Other 2GZ—ft. �elow ❑ above land surface <br /> yy --�- -�-- --�-- --;-- E CASING TYPE(S) <br /> i <br /> -'�- -�-- ------ --j--- feel ❑ Plastic ❑Tile ❑Other <br /> -- --�-- --�-- --�-- CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> t md. __._..-.. in.from to?/1 ft. ❑ Yes N Vo E] Yes E]No E] Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. E]Yes '❑ No ❑ Yes ❑ No ❑ Unknown <br /> T)arWn Car1sco 471—8111 <br /> Property owner's mailing address if different than well location address indicated above. in.from to ft. ❑Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> SCREEN/OPEN HOLE <br /> Screen from� to ft. Open Hole from to ft. <br /> OBSTRUCTION/DEBRIS/FILL <br /> WELL OWNER'S NAME Obstruction ❑ Debris ❑ Fill ❑ No Obstruction �/f}j^��'[' 7� <br /> Well owner's mailing address if different than property owner's address indicated above. Type of Obstruction/Debris/Fill -Z (UA,411 / L.!-'< 4' 4 `.! <br /> Obstruction/Debris/Fill removed? X11 <br /> es ❑ No <br /> PUMP 1� <br /> Type �/�T 117W <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO emoved ❑ Not Present ❑ Other <br /> FORMATION <br /> It not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> XNo Annular Space Exits <br /> l <br /> ❑ Annular space grouted with tremie pipe <br /> (� ❑ 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) <br /> Grouting Material 4e <br /> 44Z"_47; ��� to fL yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING UNSEALED WELLS AND BORINGS <br /> Other unsealed well or boring on property? ❑ Yes XNo <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 /> Dw Stodola Well Orillin�, Co., I1.4c. 27172 <br /> Contractor Business Name License or Registration No. <br /> u1 i,,e t Representative Signature Date <br /> Name of Person S I{ngWell or Boring ted, <br /> LOCAL COPY H 113025 <br /> HE-01434-02 <br /> 10/95R <br />