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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H �13 7 9 4
County Name
WELL AND BORING SEALING RECORD Mnnlegoa�UniqueWellNo.
�[I� in Minnesota Statutes,Chapter 1031 or W-series No.
(Leave blank il not knowni
Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed
Orono 118 23 33 NW NS , 2( U C� �
GPS Latitude degrees minutes seconds /)
/
LOCATION: Depth Before Sealing / � ft. Original Depth/�v ft.
Longitude degrees minutes seconds p IFER(S) STATIC WATEfl LEVEL
Numerical Sireet Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer
O�� � $t D� T, �� �UBORING �Measured ❑ Estimated
� x7A TUl ater Supply Well ❑MoniL Well �
Show exact location of well or boring ,�,� (;'- p of well or boring /`
in section grid with"X" �� "�' ��howing property ❑ Env.Bore Hole ❑Other �v ft. �elow ❑above land surface
N � Iines,roads,and buildings. CASING TYPE(S)
-- - - -- - - -- -- A J
r j �; , h �teel ❑Plastic ❑Tile ❑Other
-�- -�-- -;— —;-- ����`,� �/ WELLHEAD COMPLETION
W E ,a/
� � � � ('` � Outside: ❑Well House Inside: ❑Basement Offset
-;-- ;-- -;-- --�-- � , � j
p�
�^'�� � ❑ Pitless AdaptedUnit ❑Well Pit
--- -i-- -i— --�—
❑Well Pit - ❑Buried
S
, ` t ,
�rmee� �t ._ -.��. , uried
PRtO1P,.EiRTY OWNER'S NAME/CO PANY NAME CASING(S)
.valJ�$t� � �t Diameter Depth � Set in oversize hole? Annular space initially grouted?
Proper�y owner's mailiny address if different than well location address indicated above � ��
in.from� to //li� ft. ❑Yes �io ❑Yes ❑No ❑Unknown
7745 Polarfs Lane
Maple Grave, �t 55313 in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
Well owner's mailing address if diNerent than property owner's address indicated above Screen from���10��ft. Open Hole from i0 ft.
OBSTRUCTIONS
❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill [�Vo Obstruction
Type of Obstructions(Describe)
GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? ❑YBS ❑ No DeSC�ibO
FORMATION
If not known,indicate estimated formation log from nearby well or boring PUMP
� u ! .�. Type
❑ Removed [�lot Present ❑ Other
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE:
. p/ No Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal
f�
in.from to ft. ❑ Perforated ❑ Removed
in.from to ft. ❑ Perforated ❑ Removed
Type of perforator
❑ Other
GROUTING MATERIAL(S)' (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.)
,r1 � �../.�- /
Grouting Material ��/%'!T�'��.�"�Nrbfii Q to��ft. yards _� bags
from to tt. yards bags
from to ft. yards bags
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑ Yes No How many?
LICENSED OR REGISTERED CONTRACTOR CERTIFICATION
This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report is
true to the best of my knowledge.
1)on Stodols Well Drilli Co., Inc. 27272
Contractor Business Name Licer,se or Registration No.
�-�z-a3
�t z eprese tative Si _ Date
LOCAL COPY H 2 i 3 7 9 Jlu� �t�1�3�
Name ol Person Sealing Well or Boring