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WELL OR BORING LOCATION 4 ,51 <br /> 3MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 32 9 5 1 <br /> WELL AND BORING SEALING RECORD Minnesota Sealing <br /> o <br /> County Name Unique Well No. �} <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> Men <br /> p (Leave dank II-known) <br /> ne in <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono M . Z% fy)AY 15'� <br /> GPS LOCATION—decimal degrees(to four decimal places) c <br /> Depth Before Sealing ft. Original Depth ft. <br /> Latitude Longitude <br /> p�piU <br /> IFER(S) STATIC WATER LEVEL MY OF ORON <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Xingle Aquifer ❑Multiaquifer �./f��,J <br /> WELUBORING Measured ❑Estimated Date Measured r <br /> 2420 Watertown Rd Orow 55355 >'Water-Supply Well ❑Monit.Well <br /> Show exact location of well or boring Sketch map of well or boring r--Env.Bore Hole Other ft. below above land surface <br /> in section grid with"X" location,showing property ❑ ❑ ❑ <br /> N lines,roads,and buildings. CASINGTYPE(S) <br /> Steel E]Plastic El Tile ❑Other <br /> 07%-- -------- --- ------ T WELLHEAD COMPLETION <br /> W EI <br /> Outside: ❑Well House ❑At Grade Inside: E]Basement Offset <br /> 'h Mile 0 XPitless Adapter/Unit ❑Buried ❑Well Pit <br /> - -- -- ------ <br /> ��,� Buried <br /> 1 <br /> ❑Well Pit ❑Other <br /> 1 Mile <br /> A ❑Other <br /> -� LA-)i <br /> ,f„j <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> T Diam er • Depth Set in oversize hole? Annular space initially grouted? <br /> I Property owner's mailing address if diff rent than well location address indicated above . 'tin,from U to ft. ❑Yes XNo ❑Yes ❑No ❑Unknown <br /> C <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEWOPEN HOLE <br /> / ) t <br /> Well owner's mailing address if different than property owner's address indicated above Screen from l r to175 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ji Obstruction <br /> Type of Obstructions(Describe) <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? E]Yes ❑No Describe <br /> FORMATION <br /> PUMP <br /> If not kirlown,indicate estimated formation log from nearby well or boring. <br /> • 0 77 � Type_ <br /> ❑Removed of Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> [(No 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 Ibs.,one bag of bentonite=50 lbs.) <br /> Grouting Material 1V4or(f*11/-1 / from Q to 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 Wo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> 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 /> Ikon Stodola Well Drilling co.. Inc. 1691 <br /> Licensee Busingss fjlame License or Registration No. <br /> zvi <br /> e e <br /> In Signature Certified Rep.No. Date <br /> LOCAL COPY " 3 '9451 Name of Person Seating Well or Boring <br /> HE-01434-14 IC#140-0423 5/13R <br />