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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring 13 30 0:] <br /> WELL AND BORING SEALING RECORD Sealing H <br /> County Name Minnesota <br /> Unique No, <br /> Minnesota Statutes.Chapter 1031 Or W-series No. - <br /> Hennepin heave hiank if not known) <br /> Township Name Township No. Range No. Section No. Fraction Ism.�Ig.) Date Sealed Date Well or Boring Constructed <br /> rono 117 23 17 43-,013 S' ,J,c?,U qiZ <br /> Numerical Street Address or Fire Number and City of Well or Boring Location > / <br /> 3590 Northern Ave, Orono 55391 Depth Before Sealing ft. Original Depth 30 ft. <br /> Show exact location of well or boring Sketch map of well or boring IFER(S) STATIC WATER LEVEL <br /> in section grid with"X' location, showing property Single Aquifer ❑ Multiaquifer <br /> lines,roads,and buildings. <br /> N WELUBORING Measured [:1 Estimated <br /> -1 Water Supply Well ❑Monit.Well <br /> ' o ❑ Env.Bore Hole E:1 Other / it. ,TJ below El above land surface <br /> W----- - -- - - --i- E -.•- CASING TYPE(S) <br /> -�-- Steel E] Plastic E]Tile ❑ Other <br /> CASING <br /> Diameter Depth Set in oversize hole? Annualar space initially grouted? <br /> LLL S """"��J�� -- f'� ? <br /> µ- f mile in.from` to +'/ <br /> r ft. ❑ Yes )(No ❑ Yes E]No E] Unknown <br /> PROPERTY OWNER'S NAME in.from to ft. ❑ Yes ❑ No ❑ Yes ❑No ❑ Unknown <br /> 41 <br /> owner s mai mr 471 -9733 <br /> g a ds if different than well location address indicated above. in.from to ft. ❑ Yes ❑ No E] Yes E] No ❑ Unknown <br /> res <br /> SCREEN/OPEN HOLE <br /> Screen from 2L2 r to -30 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> WELL OWNER'S NAME r '" X Rods/Drop Pipe p E] Check Valve(s) E3 Debris ❑ Fill ❑ No Obstruction <br /> Well owner's mailing address if dif(er@ttpha r s address indicated above. Type of Obstructions(Describe) <br /> JA�� r ORONO Obstructions removed? Yes [j No Describe <br /> Ci,�Y V PUMP <br /> Type <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OF FROM TO El Removed Not Present El Other FORMATION <br /> It not known,indicate estimated formation log from nearby well or boring. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE: <br /> No Annular Space Exits <br /> -'� - ❑ Annular space grouted with tremie pipe <br /> E:. ❑ Casing Perforation/Removal <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> in.from to ft. ❑ Perforated ❑ Removed <br /> Type of perforator <br /> ❑ Other <br /> GROUTING MATERIAL(S) �j/ <br /> Grouting Material � ��� eo�l,) 'frrn /to�...L'ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> REMARKS,SOURCE OF DATA,DIFFICULTIES IN SEALING 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 /> This well or boning was sealed in accordance with Minnesota Rules,Chapter 4725. The information contained in this report is <br /> true to the best of my knowledge. <br /> Don Stodola tlEll Drilling co. , Inc. 27172 <br /> Contractor Business Name License or Registration No. <br /> A&thohz9d Representative signature Date <br /> Lti <br /> LOCAL COPY H <br /> 133007 Name of Person Sealing Well or Boring <br /> HE-01434-03 2/97 R <br />