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Minnesota <br /> WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No.Well and Boring H 3 7 5 4 3 9 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,Chapter 1031 o aW series.No. <br /> k if not Or) <br /> T wnship NaRein Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 17 SO th 7 it - , t/ - `- <br /> GPS LOCATION- decimal degrees(to four decimal places) / / <br /> Depth at Time of Sealing l`� ft. Original Depth ft. <br /> Latitude Longitude <br /> AO IFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer ,�( '")�,/ .. <br /> q�� ELLBORING ={(�Measured Date Measured f ';fi / 'C.-A) ❑Estimated <br /> 34s�7 Crystal Ray M t Ornno Water-Supply Well ❑Env.Well l� <br /> Show exact location of well or boring Sketch map of well or boring �- yam'below ❑above land surface <br /> in section grid with"X." �r location,sh• ing property ❑Temp.Env.Well ❑Other ft. XX``• <br /> N E f ines40oad. and bui•A '•• CASING TYPE(S) <br /> (... /4 Steel ❑Plastic ❑Tile ❑Other <br /> W <br /> --,-----,------------ ---E .-r-.,.i WELLHEAD COMPLETION <br /> Outside: ❑Pities Adapter/Unit ❑At Grade Inside: ❑Basement Offset a-,� <br /> h Mile ❑Well Pit ❑Buried ❑Well House r ,, <br /> Li Well Pit <br /> 1. ❑Other <br /> S ❑Buried j <br /> t Mile--I <br /> s,Other <1....f, 13e./ ..:1 ''1" <br /> For multiple temporary environmental wells,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from t", to 1) '717 ft. ❑Yes o ❑Yes - ❑No ❑Unknown <br /> Prope Towne s mai mgiddressifdirenT l�ialfR�aela iodre�ss indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 4741 S Lake Sarah Dr in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Maple Plain, M 55359 SCREEWOPEN1HOLE , <br /> WELL OWNER'S NAME/COMPANY NAME Screen from / / to i'•� I ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above Vods/Drop Pipe ❑Check Valve(s) jjj❑Debris El Fill ❑No Obstruction <br /> Type of Obstructions(Describe) (1--t <br /> 'JC ,+ l�} <br /> Obstructions removed? 'ces ❑No Describe \ <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR I HARDNESS OR I FROM TO Not Present 'Present,Removed Prior to Sealing <br /> FORMATION ❑ ❑Other <br /> Ott, <br /> If not known,indicate estimated formation log from nearby well or boring. Type _ <br /> ♦ I pf METHOD USED T_ EAL 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 /> asing 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 I No TN# <br /> • <br /> GROUTING MATERIAL(S) (One bag of cement_-9944 lbs.,one bag of bentonite=50 lbs.) <br /> Grouting MaterialAh4 JWI O to_ _ ft. yards / 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? ❑YesNo 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 /> - ,. 'resent-ti4.tg,'Inrc-..- Certified Rep.No. Date <br /> LOCAL COPY H 3 7 5 4 3 9 <br /> Name of Person Sealing Weer Boring AAA...) <br /> HE-01434-16 ID#53159 \j S.,....r 9/17R <br />