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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boringt'� <br /> WELL OR BORING LOCATION H 7 0 LD J <br /> WELL AND BORING SEALING RECORD Sealing No. <br /> County Name Minnesota Unique Well No. <br /> jj,�� ��jj Minnesota Statutes,Chapter 1031 oraW-seriesNo. <br /> TowfiS TPIATownship No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed / ! Date Well or Boring Constructed <br /> 1�1117� � y},7 14 ,4 ,ti /6//y I/ 9 <br /> GP i &-decimi a lees(to;our decimal places) 1W1414 <br /> / <br /> Depth at Time of Sealing 95 ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City ofWell or Boring Location Single Aquifer ❑Multiaquifer <br /> •�y/,ar�r0��'�/"��a_, 4 ., civr„ LUBORING X.Measured Date Measured �� ❑Estimated <br /> 1 t►1 Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or boring �� �D below ❑above land surface <br /> in section grid with"X." location,s wft. 1F'ing pro er Temp.Env.Well ❑Other <br /> lines,roa and buil,I <br /> N (1.„07—1 -/' (- J -,ice CASING TYPE(S) <br /> I yr Steel ❑Plastic ❑Tile ❑Other <br /> ---1-"'--'--- -`--'-- --' WELLHEAD COMPLETION <br /> w E T Outsider Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> Mile Well Pit ❑Buried WellHouse <br /> h ❑ ❑ <br /> r - 1 <br /> ❑Well Pit <br /> d ❑Other <br /> s ❑Buried <br /> Mile ) <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 / <br /> NY NAME Depth , Set in oversize hole? Annular space initially grouted? <br /> PROPERTY ER'S NAME/COMP / Q <br /> ��Q _ea___in.from � to F/ ft. ❑Yes �No ❑Yes ❑No El Unknown <br /> % <br /> Prone Stf e"s if differentt�hhaan well location address indicated above in.from to ♦ ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 1825 Pagsrn6N Point Rd in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Orono PIR 551 SCREEN/OPEN HOLE <br /> /� <br /> t/ • <br /> WELL OWNER'S NAME/COMPANY NAME Screen from 9/ to15 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above WRods/Drop Pipe ❑CheckkV^^��alve(s) ❑Debris El Fill ❑No Obstruction <br /> Type of Obstructions(Describe) ` J44) /Q / '/ 4 19141411P <br /> Obstructions removed?X Yes D No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION Li Not Present Present�,yRemoved Prior to Sealing ❑Other <br /> If nqt known,indicate estimated formation log from nearby well or boring.At4 - Type jik SU(� !/t 1 � <br /> C/..�yj 0 y� METHOD USED TO SEAL ANNULLAR4,rSPAC BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe Xing Diameter ❑Casing Perforation/Removal <br /> sing Diameter <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- 4 lbs.,one bag of bentonite=50 lbs.) <br /> I • <br /> Grouting Material from_ to 94 ft. yards_2O_ 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? ❑Yes '�Jo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION J( <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 Stodoln Well Drilling Co,. Inc. 1691 <br /> Licensee Business Name License or Registration No. <br /> A :; <br /> R /i Jt t 9 <br /> ,..+fi : <br />