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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring I I 338231 <br /> County Name <br /> WELL AND BORING SEALING RECORD MZnleso aoUnique Well No. <br /> Nennepin Minnesota Statutes,Chapter 1031 or <br /> aneries Noi. <br /> Township Name Township No. Range No. Section No. Fraction(sm.—Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 05 SK Sid SW 2-r7n-P <br /> GPS LOCATION-decimal degrees(to four decimal places) Q op <br /> Depth Before Sealing `� ft. Original Depth ft. <br /> Latitude Longitude <br /> A UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring LocationSingle Aquifer ElMultiaquifer6W Tonkaws Rd, orono /►,�y <br /> L 7WELL/BORING Measured L]Estimated Date Measured Max [A <br /> 5 SS' Water-Supply Well El Monit.Well / <br /> Show exact location of well or boring Sketch map of well ring <br /> in section grid with"X" location,showinIn <br /> Env.Bore Hole ❑Other Alft. below ❑above land surface <br /> N lines,roads,and CASING TYPE(S) <br /> \ _r Steel Ll Plastic ❑Tile ❑Other <br /> WELLHEAD COMPLETION <br /> W EI <br /> Outside: ❑Well House ;!(At Grade Inside: ❑Basement Offset <br /> %Mile ❑Pitless Adapter/Unit ❑Buried ❑Well Pit AUG 0 8 <br /> T 1l ❑Buried <br /> 115111 �� _ <br /> ❑Well Pit 2016 <br /> �1 Miley ❑Other ❑Other <br /> CITY OF ORONO <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Diameteter,♦ • Depth ♦ Set in oversize hole? Annular space initially grouted? <br /> Property owner's mai ing a dress if different than well location address indicated above in.from Q to 97 ft. ❑Yes )(No ❑Yes ❑No ❑Unknown <br /> 1700 Niagara Lane N in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Plymmth, MN 55447 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> Well owner's mailing address if different than property owner's address indicated above Screen from to-� _ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Rods/Drop Pipe ❑Check Valve(s) ❑Debris [-1Fill <br /> /�❑No Obstruction <br /> Type of Obstructions(Describe) &0#0 PIP—A f CM'u-iiI <br /> GEOLOGICAL MATERIAL I COLOR HARDNESS OR FROM TO Obstructions removed? Ky. <br /> s EJNo Describe <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP ,, •- <br /> Type (t�[� Pt►M n <br /> 1� �✓ Removed ❑Not Pretent ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> loo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <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 bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Materjal,040!W 65<//6yll.from V to--'I'T— ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING Other unsealed and unused well or boring on property? ❑Yes Xo How many? <br /> �gy�� WaLICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> NIM: Old address for property s; This well or boring was sealed in accordance with Minnesota Rules,Chapter 4725.The information contained in this report <br /> 666 TonkaWa Rd, Orono is true to the best of my knowledge. <br /> Don Stodola Well Drilling Co,. Inca 1691 <br /> Licensee Business Name License or Registration No. <br /> ,eertilied Representafive Signalbre Certified Rep.No. Date <br /> �``` .�' <br /> LOCAL COPY H 33323 Name of Person Sealing Well or Boring :1 <br /> HE-01434-14 ID#53159 5/13R <br />