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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 362 /I Q <br /> County Name o. <br /> WELL AND BORING SEALING RECORD Sealing Na Unique Well No. 9`t V <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave dank if not known) <br /> Towns Ip�a e g Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 20 1 N$ i 3-e-/1 i ‘,,0 <br /> GPS LOCATION—decimal degrees(to four decimal places) g <br /> Depth at Time of Sealing `2S ft. Original Depth �2 ft. <br /> Latitude Longitude <br /> AOUIj;ER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Ingle Aquifer ❑Multiaquifer 1 <br /> WELL/BORING M .7 <br /> easured Date Measured „3—.7-,r7 ❑Estimated <br /> 2455 Meelyunatt Rat Aram 55351 QWater-Supply Well ❑Env.Well <br /> Show exact location oT well or boring Sketch map of well or boring <br /> in section grid with"X." location,showing property ❑Temp.Env.Well ❑Other 8 ft. 2elow ❑above land surface <br /> �y,/Y� 1es,roads,and buildings. <br /> N CASING TYPE(S) <br /> ___L.. l r'�I�", <br /> IAV 4 feel ❑Plastic ❑,Tile ❑Other <br /> -----' _ WELLHEAD COMPLETION <br /> Outside:,,W'Pitless Adapter/Unit ❑At Grade Inside: El Basement Offset <br /> ...2 g <br /> %Mile ❑Well Pit ❑Buried ❑Well House <br /> --- 1 0 Other ❑Well Pit <br /> s ❑Buried <br /> F---1 Mile 1 <br /> ❑Other <br /> For multiple temporary environmental wells,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diamet r Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from to ❑Yes ❑Yes "o ❑Unknown <br /> Proper owns ss if different than well location address indicated above in.from to ft. ❑Yes 0 No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE ,�+ <br /> WELL OWNER'S NAME/COMPANY NAME Screen from to ft. Open Hole from ��to ��7 ft. <br /> OBSTRUCTIONS� <br /> ' Well owner's mailing address if different than property owner's address indicated above Imo'rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) ��� IV)11 <br /> Obstructions removed? ikoees ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL 1 COLOR I HARDNESS OR I FROM ITO <br /> FORMATION ❑Not Presentesent,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type 4-5.1V, <br /> Of F T 1...) /�.'t trj ME OD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> .S/f/ TvA/e" .j�357 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? ❑Yeso TN#_ <br /> GROUTING MATERIAL(S) (One bag of cement.94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Materialo" from a to.Z e ft. yards_ 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? ❑Yeslo How many? <br /> 1 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 Steiila Well Drilling Col, Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> V <br /> e ed -present.,".i. —' Certified Rep.No. nate. <br /> '1—CLIAsk <br /> LOCAL COPY H ('r \—�•. <br /> 3 V L J 4 V Name of Person Sealing Well or Boring <br /> HE-01434-16 ID#53159 9/17R <br />