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HE -01434-16 ID# 53159 ( �% 9117R <br />MINNESOTA DEPARTMENT OF HEALTH Mi Ing Nowell and Boring <br />WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br />Minnesota Statutes, Chapter 1031 or W--sse„ieswNo. <br />H 3 � -274.3 <br />WELL OR BORING LOCATION <br />County Name <br />T <br />y!�►1 Ai' <br />Township Nam <br />Township No.Range <br />No. <br />Section No. <br />Fraction (sm. Ig.) <br />Date Sealed)) <br />Date Well or Boring Constructed <br />n <br />.:�ti t it.T t.1 <br />�C - 3 %,L),26 <br />GPS LOCATION - decimal degrees (to four decimal places) <br />Latitude Longitude <br />t <br />Depth at Time of Sealing 1 Q if ft. <br />Original Depth <br />AQUIFER(S) <br />Single Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />_ L2d�Q Measured Date Measure' Estimated <br />It. below above land surface <br />❑ <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />1-398 Rest Point Rd- Orono - <br />WELLBORING <br />g Water -Supply Well ❑ Env. Well <br />ElTemp. Env. Well ❑ Other <br />Show exact location of well or boring Sketch map of well or boring <br />in section grid with "X.° location, showing property <br />tines, roads, and buildings. <br />N 1 <br />'--- --y-- - `- - <br />j <br />CASINGTYPE(S) <br />Steel ❑ Plastic ❑ Tile ❑ Other <br />--i--- ---- --`-- <br />WELLHEAD COMPLETION <br />W E� <br />I I <br />--�------t <br />'h Mile <br />-:--- -- <br />1 <br />S <br />Outside: Pitless Adapter/Unit ❑ At Grade Inside: El Basement Offset <br />E]t <br />Well Pit ❑ Buried ❑ Well House <br />❑ Well Pit <br />El Other <br />❑Buried <br />I--1 Mile <br />❑ Other <br />For multiple temporary environmental wells, provide additional location <br />CASING(S) <br />information, a site sketch, and geology on a separate page. <br />Diameter Depth Set in oversize hole? Annular space initially grouted? <br />in. from to ft. ❑ Yes No E] Yes ❑ No El Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />La <br />in. from to ft. ElYes E]No E]Yes [-]No ElUnknown <br />ProjKlrlsiklllng address if ifferent than well location address indicated above <br />11401 Cty Rd. 3 <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />Hopkins, W 55443 <br />SCREEWOPEN HOLE <br />Screen from /09 L to 11JR ft,Open Hole from to ft. <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS <br />IF7 Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Well owners mailing address if different than property owner's address indicated above <br />Type of Obstructions (Describe) _ ) <br />Obstructions removed? Yes ❑ No Describe <br />PUMP <br />❑ Not Present Present, Removed Prior to Sealing ❑ Other <br />Type <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />If nol known, Indicate estimated formation log from nearby well or boring. <br />Q <br />METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />No Annular Space Exists El Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal <br />Casing Diameter <br />in. from to ft. ❑ Perforated ❑ Removed <br />in. from to ft. ❑ Perforated ❑ Removed <br />Type of Perforator <br />—_ <br />VARIANCE <br />Was a variance granted from the MDH for this well? ❑ Yes X,No TN# <br />GROUTING MATERIAL(S)11 (One bag of cement = 94 lbs., one bag of bentonite = 50 lbs.) <br />Grouting Material- 0-4, r-2, trom—�/ to /1J-& 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? ❑ Yes VNo 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 />REMARKS, SOURCE OF DATA, bIFFICu L•S IN SEALING <br />1, <br />Ton Stodola Well Drilling Co. Inc. 1691 <br />APR 0 3 2020 <br />Licensee Business Name License or Registration No. <br />CITY OF ORONO <br />.'��� <br />C rfi re'sentativ i att re Certified Rep. No. Date <br />LOCAL COPY <br />H72743 <br />Name of P rson Sealing ell or Boring <br />HE -01434-16 ID# 53159 ( �% 9117R <br />