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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 355460 <br /> Sealing <br /> County Name WELL AND BORING SEALING RECORD Minneso aOUnique Well No. <br /> No. <br /> Hennepin Minnesota Statutes,Chapter 1031 or W-series N <br /> (Craw blank M not No. <br /> Township Name Township No. Range No. Section No. Fraction(sm.-,Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23_ 20 _ 1:11 ttE 141.4 2./ ie <br /> GPS LOCATION-decimal degrees(to four decimal places) 00. / <br /> Latitude Longitude Depth at Time of Sealing /V/ ft. Original Depth ft. <br /> IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer �f R <br /> 25'>R 7 � Y ��' OronofW LL/BORING y�Measured Date Measured' /}� II]Estimated <br /> W �d((Water-Supply Well ❑Monit.Well 7a r <br /> Show exact location of well or boringEnv.Bore Hole Sketch map of well or boring <br /> in section grid with"X" location,showing property ❑ ❑Other 6! ft.*below ❑above land surface <br /> N I+, lines,roads,and buildings CASING TYPE(S) <br /> Ql, NA Steel ❑Plastic ❑Tile ❑Other <br /> .. ----''---- ----_f--" WELLHEAD COMPLETION <br /> ;___ I Outside: ❑Pitless Adapter/Unit ❑At Grade Inside)(on <br /> Basemen <br /> 'h Mile .E:. R 0 Z 2418 <br /> ❑Well Pit ❑Buried ❑Well House <br /> 1 '� ID Other ❑Well Pit <br /> 1 1 Mile —1 �`ror/ ❑B�,;edCllY OF ORONO <br /> _, J ❑Other <br /> PROPERTY OWNER'S NAME/COMPANY NAME CASING(S) <br /> Tim »t" Diameter Depth I Set in oversize�/// hole? Annular space initially grouted? <br /> Property� owner <br /> 'mailing,address ft different than well <br /> lllocation address indicated above g/f in.from to/5 ft. ❑Yes XNo ❑Yes ❑No ❑Unknown <br /> 4931 Vincennes Ci; ftp in.from to - ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Cape Coral, FL 33904 <br /> in.from to ft. Li Yes ❑No ❑Yes ❑No ❑Unknown <br /> WELL OWNER'S NAME/COMPANY NAME SCREEN/OPEN HOLE <br /> r <br /> Well owner's mailing address if different than property owners address indicated above Screen from /53to./51 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> yRods/Drop Pipe ❑Check Valve(s) ❑Debris Li Fill ❑No Obstruction <br /> - Type of Obstructions(Describe)aots4 024145 } e:, <br /> ,72,14,45 <br /> HARDNESS OR Obstructions removed? <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO XYes ❑No Describe- <br /> If no known,indicate estimated formation log from nearby well or boring. <br /> PUMP <br /> ,r� 'Il�Not Present ❑Present,Removed Prior to Sealing ❑Other <br /> 5 6 451 fTy*pe <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 /> 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 No TN# <br /> GROUTING MATERIAL(S) (One bag of cement= lbs.,one bag of bentonite=50 lbs.) <br /> • <br /> Grouting Materi0W47—C646177 <br /> r� from _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? ❑YesVI o How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION f <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 /> Don Stodola Well Drilling Co. Inc, 1691 <br /> Licensee Business Name License or Registration No. <br /> .. 2 - I - !a <br /> C eserftative S' ature Certified Rep.No. Date <br /> LOCAL COPY " 355460 r ' " ``~'" ''' <br /> yytt <br /> Name of Person Sealing Well or Bo tng <br /> HE-01434-15 ID#53159 ' ensA <br />