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WELL OR BORING LOCA7ION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �O�O[�O <br /> County Name <br /> WELL AND BORING SEALING RECORD MinnlesoNa Unique Well No. J <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> � (Leave blank'ii not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm->Ig) Date Sealed Date Well or Boring Constructed <br /> 4rvno 117 23 17 2''3-0032 � — <br /> GPS La[itude degrees minutes seconds � / r <br /> LOCATION: Depth Before Sealing �.�L�� ft. Original Depth ��C�s tt. <br /> Longitude degrees minutes seconds qQU1FER(S) STATIC WATEq LEVEL <br /> Numerical Street Address or Fire Number and City of Weil or Boring Location ingle Aquifer ❑Multiaquifer <br /> 1865 Concordia St � Orono 55391 WELUBORING �aMleasured ❑Estimated <br /> T <br /> �Water Supply Well ❑Monit.Well i <br /> Show exact location of weil or boring Sketch map of well or b'ring c, �" <br /> in section grid with"X" location,showing prope � ❑ Env.Bore Hole ❑Other J � ft. �below ❑above land surface <br /> lines,roads,and buildin g� <br /> N `,� -�-�1 CASING TYPE(S) <br /> � � ' ' ! <br /> -'i-- --i-- `—� �) ' <br /> ��„k` teel ❑Plastic ❑Tile ❑Other <br /> W --�- - - -- --i-- E .�� WELLHEAD COMPLETION <br /> , � � � � �_-.�. Outside: ❑Well House Inside: ❑Basement Offset ��� <br /> -�-- -�-- ' �— .'. <br /> �^"� ❑PitessAdapter/Unit ❑WeIIPit <br /> --�- -i-- -�-- --�-- I <br /> 1 �VVell Pit ❑Buried <br /> S y /� <br /> �r mne---�w '\ <br /> i ❑Buried <br /> PROPERTY DOWNER'S NAME/COMPANY NAME CASING(S) <br /> T0� U CQ'n AOQie s Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different ihan well location address indicaled above � � <br /> _��In.ffom� to��ft. ❑Yes �No ❑Yes ❑No ❑ Unknown <br /> 7526 Turner Rd <br /> Independence, MN 55328 in.from ,o ft. ❑Yes ❑No ❑Yes ❑No ❑ Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑ No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r / <br /> Well owner's mailing address if diflerent than property owner's address indica�ed above Screen from�(�t0 /7�ft. Open Hole from t0 ft. <br /> OBSTRUCTfONS <br /> L�Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br /> Type of Obstructions(Describe)� .�/'r/� �T�r:%Y ¢ �'�it jw/��� <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? eS ❑ NO DBSCfib2 <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring PUMP <br /> d C i f t % 0 2 6 TYPe�-T(?G I�L��� <br /> emoved ❑ Not Present ❑Other <br /> METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> QiM1lo Annular Space Exists ❑ Annular space grouted with tremie pipe ❑ Casing Perforation/Removal <br /> ��. <br /> in.from to ft. ❑ Perforated ❑ Removed - <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of peHorator <br /> ❑ Other <br /> GROUTING MATERIAL(S) (One bag of cement=94 Ibs.,one bag of bentonite=50 Ibs.) <br /> Grouting Material /L`,�r%�L���.uT from�to�h' 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 o 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 is <br /> true to the best of my knowledge. <br /> z-u�...,aa....:r i...�iiJj <br /> Don Stodols We1lDrilling�,. Inc. 27].]?. <br /> e'''''� Contractor Business Name License or Re istration No. <br /> �������� 2 5 �R�� - 9 <br /> _ . -. <br /> GITY U1=ORO�Vp - <br /> A ri d resentative Signat - ' Date <br /> /� ^/�^ Jim #ntonson <br /> LOCAL COPY H L O /1 1�.i O Name of Person Sealing Well or Boring <br /> L4�J <br />