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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 6 5 8 2 4 <br /> County Name WELL AND BORING SEALING RECORD M <br /> Sea <br /> oUnique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> (Leave dank if not known) <br /> TowNR11011 Township No. Range No. Section No. Fraction(sm.-Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono IIT 23 01 Ili Sa ii 6./2 /19 <br /> GPS LOCATION-decimal degrees(to four decimal places) 0 <br /> Depth at Time of Sealing /04 ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location yXSingle Aquifer ❑Multiaquifer <br /> 'WELL/BORING X Measured Date Measuredliene_2141eL Estimated <br /> �ater-Supply Well ❑Env.Well a <br /> Show exact location of well or boring Sketch map of well or boring U Env.Well Other /� ft. X below above land surface <br /> in section grid with"X." location,showing property Temp. ❑ (fi ❑ <br /> N lines,roads,and build igs`. CASING TYPE(S) <br /> y (f[ <br /> _} *eel Plastic ❑Tile ❑Other <br /> J WELLHEAD COMPLETION <br /> E p Outslde:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'IIA Mile • ❑Well Pit ❑Buried ❑Well House <br /> d ❑Other LI ❑Well Pit <br /> s } <br /> ❑Buried <br /> 1 Mile h <br /> ❑Other <br /> For multiple temporary environmental wells,provide 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 fn.fromte/� to ft. ❑Yes No ❑Yes ❑No ❑Unknown <br /> p i <br /> Prone s mai i rens if different than well location address indicated above in.from r - to ft. ❑Yes ,❑',No ❑Yes ❑No ❑Unknown <br /> 2435 %mutts lilvd is in.from to ft. 111Yes ❑No ❑Yes ❑No ❑Unknown <br /> tang law, IN 55356 SCREEN/OPEN HOLE <br /> �qf <br /> WELL OWNER'S NAME/COMPANY NAME a <br /> Screen from Jaz. r to /cas 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) fN . T Sue //rir <br /> Obstructions removed? "Q�Yes ❑No Describe <br /> PUMP �'i� <br /> HARDNESS OR <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO ❑Not Present resent,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type 5 V L3 Ai rn� <br /> d <br /> /( /®L METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> �.J ) Aa o Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> ing 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 beg of cement- 4 lbs.,one beg of bentonite a 50 lbs.) <br /> Grouting Material omL toi_ot.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? ❑Yes XNo How many? n. <br /> LICENSED OR REGISTERED CONTRACTORCERTIFICATION. t" ,':, i .,. <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING This well or boring was sealed in accordance with Minnesota Rules,Chapter 4721'he informacontained in this report <br /> ,is true to the best of my knowledge. <br /> Don Stgdoia Well Drilling Co;. Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> j - d 1 <br /> Certified Rep.No. Date <br /> LOCAL COPY " 3 6 5 8 2 4 .,-, . <br /> Name of Person Sealing Well or Bonin <br /> HE-01434-16 ID#53159 ymp <br />