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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring3 5 1 <br /> WELL OR-BORING LOCATION Sealing No. H ' 15 4 <br /> County Nam, WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> pMinnesota Statutes,Chapter 1031 or W a. a erinot es No. <br /> n) <br /> Township Ramei° Township No. Range No. Section No. Fraction(sm.–.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 35 /§W''SE'ASW $/XV/e <br /> GPS LOCATION–decimal degrees(to four decimal places) / <br /> Depth at Time of Sealing flat 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 Single Aquifer ❑Multiaquifer <br /> WELL/BORING Measured Date Measuredy_ ❑Estimated <br /> 541 North Strom" Rai Orono 553972 Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or.•r g rater-Supply <br /> Env.WellOther _ft. X1 below above land surface <br /> in section grid with"X:' location,showing prop= Temp. E ❑ <br /> lines,roads,and buildi •s <br /> N CASING TYPE(S) <br /> XSteel ❑Plastic ❑Tile ❑Other <br /> –4-4-----F------- /� Fi..... WELLHEAD COMPLETION <br /> W ET (J 11' Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: Basement Offset <br /> 'h Mile •ya"Nit I ❑Well Pit ❑Buried ❑ ell House <br /> - --T-- I ❑Well Pit <br /> yip ❑Other• <br /> ❑Buried <br /> I i Mile y—I <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 i Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME V/,in.from V to/9� ft. ❑Yes XNo ❑Yes ❑No ❑Unknown <br /> Property <br /> owner Monicamai mg a rens l different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> n.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE <br /> WELL OWNER'S NAME/COMPANY NAME �r Screen from deg , to'82 /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 SINo Obstruction <br /> Type of Obstructions(Describe) _ <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUMP <br /> HARDNESS.OR <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM •TO Not Present ❑Present,Removed Prior to Sealing _ ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type <br /> dA,A yF b f,32 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> /� J6/1/No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> (//) Casing Diameter <br /> in.from to ft. ❑Perforated ❑Removed <br /> ` <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 No TN# <br /> GROUTING MATERIAL(S) (One bag of cement= 4 lbs.,one bag of bentonite=50 lbs.) <br /> / / <br /> Grouting Materia 2 <br /> from_ . to / .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? ❑YesXNo How many? <br /> 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 Stodola Well Driling Co.. Inc. 1691 <br /> Licensee Busine s Name License or Registration No. <br /> /� , <br /> 8 -30- I8 <br /> e Yepf :- Ive ignature Certified Rep.No. Date <br /> LOCAL COPY H \ NYill' t. v <br /> 3 5 915 4 Name of Person Sealing Well\o Wong <br /> HE-01434-16 ID#53159 tt 9/17R • <br />