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-., S MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 375546 <br /> WELL OR BORING LOCATION Sealing No."!,-,,, <br /> WELL AND BORING SEALING RECORD <br /> County Name Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 or W-series NO.' <br /> wo .kinwknownr. • 5 5 LI <br /> mwq 56 <br /> Totrirotgdan Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 05 Pit SW NE 7 . ;?c, 7 -15/ <br /> GPS LOCATION-decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 9 7 ft. Original Depth 9-7 ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location X Single Aquifer 0 Multiaquifer <br /> WELUBORING..--''' ' yr Measured Date Measured "7- r2-,20 0 Estimated <br /> 3560 Bayside Rd, orono <br /> VI Water-Supply Well 0 Env.Well <br /> Show exact location of well or boring Sketch map of well or boring ,-, <br /> in section grid with"X." is,.. location,showing property Li Temp .Env.Well El Other V,- ft. X below r]above land surface <br /> N lines,roads,and buildings. <br /> CASING TYPE(S) <br /> 1 tz Steel 0 Plastic Li Tile 0 Other <br /> i . . <br /> r . WELLHEAD COMPLETION <br /> w : E T <br /> i Outside: Pitless Adapter/Unit 0 At Grade Inside: 0 Basement Offset <br /> 'fi Mile '4 0 Well Pit 0 Buried 0 Well House <br /> 1 0 Other 0 Well Pit <br /> S El Buried <br /> I 1 Mile I CI Other <br /> For multiple temporary environmental wells,pr Nide a.."- al location CASING(S) <br /> information,a site sketch,and geology on a se.arate page. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME Li,/__ in.from K.) to__42._ft. 0 Yes ijki No 0 Yes 0 No 0 Unknown <br /> Wichenhauser Excavating <br /> Properly owner's mailing address if different than well location address indicated above in.from to ft. 0 Yes El No 0 Yes 0 No 0 Unknown <br /> 13650 Cty Rd 41 in.from to ft. 0 Yes 0 No EI Yes 0 No 0 Unknown <br /> Cologne, MN 55322 <br /> SCREEN/OPEN HOLE <br /> Screen from 5702, to 9 7 ft. Open Hole from to ft. <br /> WELL OWNER'S NAME/COMPANY NAME . <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above X Rods/Drop Pipe 0 Check Valve(s) 0 Debris 0 Fill 0 No Obstruction <br /> Type of Obstructions(Describe) i I -* *_..,...".• <br /> Obstructions removed? Si Yes 0 No Describe <br /> PUMP <br /> ' • GEOLOGICAL MATERIAL COLOR HARDNESS ORFROM TO 0 Not Present IA Present,Removed Prior to Sealing 0 Other <br /> FORMATION <br /> If not known,indicate estimated formation log from nearby well or boring. Type &-, 0.....,---y-,ef•isz.-usa-ift- <br /> 0 /7METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> XNo Annular Space Exists 0 Annular Space Grouted with Tremie Pipe Li Casing Perforation/Removal <br /> Casing Diameter <br /> in.from to ft. 0 Perforated 0 Removed <br /> in.from to ft. 0 Perforated 0 Removed <br /> Type of Perforator <br /> VARIANCE <br /> Was a variance granted from the MDH for this well? Li Yes X No TN# <br /> GROUTING MATERIAL(S) (One bag of cement=94 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting Material/X2 41.... ... 6-17,-*--,*om_Cf2to 97 fi. .yards0 .... 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? i''Q YesgNo How many? <br /> LICENSED OR REGISTERED CONTRACTOR CERTIFICATION <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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,. rite -- 1691 <br /> Licensee Business Name License or Registration No. <br /> 17H <br /> ,-•"' -Air , g- ‘ '"" C7?(..) <br /> ,,AMIr. - 1 <br /> C- ifi:. t•'..esefita ivq,-.9 gnat"Fe - Certified Rep.No. Date <br /> LOCAL COPY H 375546 Name of Person Sealing Well or Boring ''', 60....n.A-.1 <br /> HE-01434-16 ID#53159 i...-' 9/17R <br />