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ti , • <br /> WELL OR BORING LOCATION-g. MINNESOTA DEPARTMENT OF HEALTH, Minnesota Well and Boring I„I' 387538 <br /> �8 7 5 3 8 <br /> -WELL AND BORING SEALING RECORD Sealing No. J(� Q <br /> County Name ;,,•. - f-.' Minnesota Unique Well No. <br /> • Minnesota Statutes,chapter 1031 orraW-serie. .s No. <br /> .. iennepin . <br /> Township Name Township No. Range No. Section No. Fraction(sm.•.Ig:) Date'Sealed Date Well or Boring Constructed <br /> Orono 117 23'' 03 N Oi RW 'IN 01 712121 • <br /> 'GPS LOCATION-decimal degrees(to four decimal places) <br /> • <br /> Depth at Time of Sealing '"'• ft. Original Depth ft. -- <br /> Latitude Longitude • <br /> - <br /> AQUIFER(S) STATIC WATER LEVEL . <br /> Numerical Street Address or Fire Number and City of Well or Boring Location jf Single Aquifer ❑.Multiaquifer • Z/2121 <br /> WELL/BORING X Measured Date Measur ❑Estimated <br /> 2250 Longview Crl, Orono X Water-Supply Well ❑Env.Well <br /> Show exact location of well or.boring 553S6Sketch map of well or boring <br /> in section grid with"X" location,showing property El temp.Boring • Iii Other ft. ❑below CI above land surface <br /> lines,pQ ds -nd buildings. <br /> N C' CASING TYPE(S) z- <br /> ' LernVt It 10 <br /> X Steel ❑Plastic ❑Tile ❑Other <br /> ---'--- --`--'--'`--- •• . WELLHEAD COMPLETION <br /> W ET ktisf.,-- <br /> Outside: Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> Mile .0 Well Pit ❑ <br /> Buried• ❑Well House <br /> 1 r 1 <br /> D Pit <br /> S - ❑Other '• ❑Buried <br /> 1 Mile---�. -- -• <br /> ^"❑Other - <br /> x <br /> For temporary.borings,provide additional to CASING(S) <br /> information,a site sketch,and geology on a separate paw " "" Diameter 4 Depth.y Set in oversize hole? Annular space initially grouted? <br /> PROPERTY�OWNE�R,'S NAME/COMPANYt � � NAME • 4 in.from 1 to 125 ft. ❑Yes ❑No ❑Yes ❑No Unknown <br /> Pr eriy owners making�addressif Efferent than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEWOPEN HOLE <br /> WELL OWNER'S NAME/COMPANY NAME WELL <br /> from 125 to 1.29 ft.. Open Hole from to ft. <br /> • OBSTRUCTIONS <br /> , Well owner's mailing address if different than property owner's address indicated above jJ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction ' <br /> Type of Obstructions(Describe) droop Pipe <br /> • Obstructions removed? Yes ❑No Describe . <br /> PUMP , <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present Present,Removed Prior to Sealing ❑Other <br /> FORMATION ❑ G <br /> If not known,indicate estimated formation log from nearby well or boring. Type` <br /> drift 1 129 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE r <br /> 1 ®No Annular Space Exists ❑Annular Space Grouted with Tremie Pipe• ❑Casing Perforation/Removal <br /> Casing 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) ��+r,�,�,,,,,..,, - r► <br /> • _ Grouting Material Neat Cel!ent from 1 to 129 ft. yards 10 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? ❑Yes ®No 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. .Inc. 1691 <br /> • Licensee Business Name ,. License or Registration No. <br /> • <br /> -' ,, 2691 . . <br /> 9"�resentative`Signature i' Certified Rep.No. Date <br /> s <br /> Y <br /> LOCAL COPY • H 3875 3 8 Jerry Barr <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 , 11/1913 <br />