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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H —ski2 1 0 1
WELL OR BORING LOCATION Sealing No.
WELL AND BORING SEALING RECORD
County Name Minnesota Unique Well No.
Minnesota Statutes,Chapter 1031 or W-series No. CEIVr"
Township Name Township No. Range No. Section No. Fraction(sm.-)Ig.) Date Sealed Date Well or Boring Constructed I U
117 2 $ 2ol,i L. ,,:'Af. ."1,,4 'A
O
CITY F On.DNO
GPS LOCATION-decimal degrees(to four decimal places) 1
Depth at Time of Sealing 2Ce) ft. Original Depth ft.
Latitude Longitude
AQUIFER(S) STATIC WATER LEVEL
.-
Numerical Street Address or Fire Number and City of Well or Boring Location y_l Single Aquifer 0 Multiaquifer
WELLJBORING Measured Date Measured -,...g rnA- 14N"Y E Estimated
..,L.io Dunwoody Ave Orono, fi-, -ii,.....,lc.1
li - -VrWater-Supply Well 0 Monit.Well
.., ,.../
Show exact location of welt or boring
in section grid with"X." lSokceatt?ohnmsat%owfi showing
Iroorp*g ,—.
L j Env.Bore Hole E Other (..,114‘.1 ft. )114below 0 above land surface
'
N : ads,and buildit ,;., /.
CASING TYPE(S)
----:,------:,- i-
.
Steel 0 Plastic 0 Tile 0 Other
WELLHEAD COMPLETION .
,. .
w
r E —,.
T __. 5. )2
7" OutsideX 01 Pitless Adapter/Unit At Grade Inside: E Basement Offset
'h Mile ,4 ' -;,i D Well Pit 0 Buried 0 Well House
. , .
--- -_,_ ,. t1 * i
\,,, 0 Well Pit
) 1 0 Other
S '---...-: .......1/ /Th . 0 Buried
1-----1miln-----1 ____—.--"- 0 Other
PROPERTY OWNER'S NAME/COMPANY NAME CASING(S)
-•Ce •Li‘..-i.1- ,../ Diem _
d.,/ Depth f Set in oversize hole? Annular space initially grouted?
Property owner's mailing address if different than well location address indicated above ii 1 in.from 1J to /96 ft.
0 Yes X No 0 Yes E No LI Unknown
in.from to ft. 0 Yes 0 No 0 Yes E No LI Unknown
in.from to ft. E Yes 0 No 0 Yes 0 No 0 Unknown
//.
WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE
I
Screen from /WO t2e...6 ft. Open Hole from to ft. ' 4,Well owner's mailing address it different than property owner's address indicated above
OBSTRUCTIONS
0 Rods/Drop Pipe D Check Valve(s) 0 Debris 0 Fill XNo Obstruction
'. .
Type of Obstructions(Describe) ,
GEOLOGICAL MATERIAL COLOR 112,DZE,71,7 FROM TO Obstructions removed? E Yes 0 No Describe ..
. _
If not known,indicate estimated formation log from nearby well or boring. PUMP
' 'Not Present /Present,Removed Prior to Sealing El Other
,4 AI
A Type
METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE
XNo Annular Space Exists 0 Annular Space Grouted with Tremie Pipe 0 Casing Perforation/Removal
Casing Diameter
in.from to ft. 0 Perforated 0 Removed
in.from to ft. 0 Perforated 0 Removed
Type of Perforator
VARIANCE
Was a variance granted from the MDH for this well? 0 Yes No TN# . -• -
GROUTING MATERIAL(S) (One bag of cement- 4 lbs.,one bag of bentonite=50 lbs.) ,./.
_ 1
.. o
Grouting Materia from__________to 240 ft. yards/en bags
.;.
from to ft. yards bags
...-. i
from to ft. yards bags i
i•
OTHER WELLS AND BORINGS
REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? 0 Yes X'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.
DON STODOLA WELL DRILLING CO. INC. 1 ').1. --...-.
. Licensee Business Name License or Registration No.
558 A')- - 1 7 •,
•
Ci-- reenla-live?Signature Certified Rep.No. Date
...,—
- ,
, ...,
. , LOCAL COPY H 3 5 2 1 0 1. tv • 1....0; -,----,
Name of Person Sealing Well or Boring ;74---V-Y.--- '' • -1.. ' -- •
HE-01434-15 ID#53159 8/169,'
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