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4 MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 253342 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD S aliiesotaoUnique Well No. H <br /> County Name <br /> Minnesota Statutes,Chapter 1031 or W-series No. <br /> 4.....01.101m1...0 <br /> Towns tPFP ownship No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono <br /> 118 23 35 134/003. 3 GCT £ <br /> GPS Latitude degrees minutes seconds Depth Before Sealing / 2 f 2 <br /> tft. Original Depth ft. <br /> LOCATION: Longitude degrees minutes seconds <br /> AGUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer <br /> WfLL/BORING X Measured ❑Estimated Date Measured <br /> Water-Supply Well ❑Monit.Well f <br /> Show exact location of well or bo getch map of of well or boring <br /> in section grid with"X" location,showing property ❑Env. Bore Hole ❑Other ?i ft. below ❑above land surface <br /> lines,roads,and buildins. <br /> N CASING TYPE(S) <br /> y ,� ❑Steel E Plastic ❑Tile ❑Other <br /> WELLHEAD <br /> ❑Well COMPLETION <br /> t t <br /> w E tL <br /> ___.__ __,__; Outside: House ❑At Grade Inside: ❑Basement Offset <br /> k Mile XPitless Adapter/Unit El Buried ❑Well Pit <br /> - ----T---- -- - 1 <br /> n ❑Well Pit El Buried <br /> S '°' l ❑Other ❑Other <br /> 1 Mile l../ <br /> PROPS TY OWNER' NAME/ MPANY NAME j CASING(S) <br /> "�+" Onsttoct3on Dig.Iv /^y f Depth J Set in oversize hole? Annular space initially grouted? <br /> Property owner's mailing address if different than well location address Indicated above in.from / to / ft. ❑Yes No ❑Yes <br /> 6583 158th St W, Ste 116C <br /> ❑No ❑Unknown <br /> Apjle Val1 ,i 55124 in.from to 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 /> Well owner's mailing address if different than property owner's address indicated above Screen from 43 to /4/19 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WRods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) _f /1f ..n rd :. it tJme <br /> HARDNESS OR <br /> GEOLOGICAL MATERIAL COLOR FORMATION FROM TO Obstructions removed? Xes ❑No Describe <br /> If not known,indicate estimated formation log from nearby well or boring. PUMP �} <br /> dt,�] Type Sue Pom <br /> r U 1 7+y Removed <br /> ❑Not Pre ant El Other <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 /> in.from to ft. ❑Perforated ❑Removed <br /> in.from_ to ft. E Perforated ❑Removed <br /> Type of Perforator <br /> ❑Other <br /> GROUTING MATERIAL(S),�/�L (One beg <br /> �of�cement=94 Ibs.,one bag of benftpnite=50 lbs.) I .terry <br /> Grouting Materiale'"'r19/ <C�`tff ° f to /S"ft. yards ! G. 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? E Yes)(No 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 /> Don Stodola Well Drilling m-, Inc- 1691 <br /> Contractor Business Name License or Registration No. <br /> 419 <br /> (00$(' ;,�►�.• /d-1. a 4 <br /> ative Signe,e Certified Rep.No. Date <br /> p <br /> H253342 s. <br /> LOCAL COPY Name of Person Sealing Well or Boring f <br /> HE-01434-09 IC#140-0423 <br /> 6/O6R <br />