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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well d BoringH <br /> WELL OR tiORING LOCATION Sealing No. 3521_76 <br /> Coun Name WELL AND BORING SEALING RECORD <br /> Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> 1 (Leave blank H rqt knovm) <br /> Township Name 1 Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orman It7 23 21 .Nti N1 N*i / /to /1 <br /> GPS LOCATION–decimal degrees(to four decimal places) / i <br /> Depth at Time of Sealing at- ft. Original Depth ft. <br /> Latitude Longitude <br /> IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑.Muitaquifer ,MM <br /> 2570 Lydiard Ave, Orono WELL/BORING Measured Date Measured AMC )5,0 klij Estimated <br /> �N/nv.Bore Hole ater-Supply Well ❑Montt.Well <br /> Show exact location of well or boring Sketch map of wet or boring ALS.E <br /> in section grid with"X" location,showing property ❑Other _ _ft.%below ❑above land surface <br /> N • lines,roads,ab du it CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> WELLHEAD COMPLETION — <br /> W ET --- RECEIVED <br /> Outside:gPitless Adapter/Unit ❑At Grade Inside: <br /> ❑Basement Offset <br /> 7 'k Mile ['Well Pit ❑Bried a Well House <br /> ❑Other Well Pit JAN 7 6 2018 <br /> S , <br /> �1 Mile ( ❑Buried <br /> ❑Other CITY OF ORONO <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> nr0g (11411rk Diame es) r Depth Set in oversize hole? Annular space initially grouted? <br /> Property otbfter's Mailing address if different than well location address indicated above // <br /> in.from © to 3 r i ft. Ill Yes X.No ❑Yes ❑No ❑Unknown <br /> 5585Harding Lanein.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Sharevood, >I 55331 <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> + f 1 <br /> Well owner's mailing address if different than property owner's address indicated above Screen from 3# toi.. ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> , f <br /> pQ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill <br /> j� ❑No Obstruction <br /> Type of Obstructions(Describe)j4$J ,R (- . An9/0 <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Obstructions removed? Yes <br /> FORMATION <br /> No Describe <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP <br /> Not Present ❑Present,Removed Prior to Sealing ❑Other <br /> u Type_ <br /> METHOD USED TO SEAL ANNU AR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> Xaso Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal <br /> mg 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 X No TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material A1fgreeinfildrom 0 to 3s ft. yards25- 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 XNo 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 /> Doti Stodola Well i, Tim; Co,. Inc. 1691 <br /> • Licensee Busine s me License or Registration No. <br /> ` .f 1. -,//' / <br /> Ce ifi a esentative Signature Certified Rep.No. Date <br /> LOCAL COPY H 352176 ,�-I , �. F. . .. <br /> Name of Person Sealing Well or Borng' <br /> HE-01434-15 ID#53159 <br /> 8/16R <br />