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HE -01434-17 ID// 53159 V 11/19R <br />MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />WELL AND BORING SEALING RECORD Minning No. <br />Unique Well No. <br />Minnesota Statutes, chapter 1031 roar W—sseri�swNo. <br />'.,I 381-37 1 -3 7 % <br />Q J 1 f <br />WELLOR BORING LOCATION <br />benne in <br />Township Name <br />Township NoZRange <br />W. <br />Section No. <br />Fraction (sm. — Ig.) <br />Date Sealed <br />Date Well or Boring Constructed <br />Orono <br />1117 <br />23 1 <br />67 <br />Sh 9, 'k <br />1 16 <br />GPS LOCATION — decimal degrees (to four decimal places) <br />Latitude Longitude <br />Depth at Time of Sealing 'ft. <br />Original Depth ft. <br />AQUIFER(S) <br />Ingle Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />ry <br />La Measured Date Measured �`� ❑Estimated <br />/ <br />4 <br />•! ft. elow ❑ above land surface <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />kJ 9 tai j 15 o U <br />ELL/BORING <br />Water -Supply Well ❑ Env. Well <br />Temp. Boring ❑ Other <br />Show exact location of well or boring - Sketch map of well or boring <br />in section grid with "X." location, showinggg property <br />N lines, roads, Ildings <br />CASING TYPES) <br />Steel ❑,Plastic ❑ Tile ❑ Other <br />-i----- r-- - - ---t! <br />I i i I <br />WELLHEAD COMPLETION <br />! <br />W I I E T <br />; e <br />T-- ------------i - 1 <br />S <br />�1 Mile <br />Outside: itless Adapter/Unit ❑ At Grade Inside: ❑ Basement'Offset <br />"❑ Well Pit U Buried EI•Vyell House <br />❑ Other El Well Pit <br />❑ Buried <br />.� <br />El Other <br />For temporary borings, provide additional location ; 'moi <br />Information, a site. sketch, and geology on a separate page. [� _...11 <br />CASING(S) <br />DiargLetr Depth Set in oversize hole? Annular space initially grouted? <br />in. from to ft. ❑Yeso El ElNo E! Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Property owner's mai Ing a dres i i t th �, o t dr d-dbove <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />1-5235 65th piaca N <br />in. from to ft. El Yes E) No El Yes ❑No ❑Unknown <br />Pl a p s e, Grove, It N 55311 <br />SCREEWOPEN HOLE <br />Screen from to A' ft. Open Hole from to ft. <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS <br />YRods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill ❑ No Obstruction <br />Well owner's mailing address if different than property owners address indicated above <br />Type of Obstructions (Describe) <br />Obstructions removed? Yes ❑ No Describe <br />PUMP <br />Not �y reset, Removed Prio to Sealing <br />❑t Present n( G. g ❑ Other <br />Type Z- ; i <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />If not own, indicate estimated formation log from nearby well or boring. <br />METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE <br />Wo Annular Space Exists ❑ Annular Space Grouted with Tremie Pipe ❑ Casing Perforation/Removal <br />as ng Diameter <br />in. from Ao 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 o TN# <br />GROUTING MATERIA S) <br />Grouting Material r :om 0 to0-3 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? ❑ Yes c 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 />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />Is true to the best of my knowledge. <br />DON S`IODOLA WELL DRILLING CO., INC. 1691 <br />Licensee Business Name License or Registration No. <br />Ceoeo�. e ase fativeSl�ture Certified Rep. No. Date <br />6 3 <br />LOCAL COPY <br />H381377 <br />Name of Person Sealing Well or Boring <br />HE -01434-17 ID// 53159 V 11/19R <br />