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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing No. <br /> and Boring H 3 8 0 6 8 4 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> Rspin Bea desk if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-+Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 11R 21 15 mit c* fit /0 • 1 7 - '�' <br /> GPS LOCATION-decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 1641 ft. Original Depth ft.Latitude Longitude <br /> A UIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer {(� <br /> 900 Lake <br /> R� 0�� ELL/BORING Measured Date Measured r " 1 -, 'rT(. ❑Estimated <br /> i�taRg , • Water-SupplyrinWell ❑Env.Well ,.-� <br /> Show exact location of well or boring Sket h map f well or borin ___9;___J� <br /> in section grid with"X" local n,sh Temp.Boring ❑Other ft. y below ❑above land surface <br /> and buildings. <br /> N lines roads, CASING TYPE(S) <br /> i L <br /> 1,�. �,.�,.,i y�Steel ❑Plastic ❑Tile ❑Other <br /> -- -----'-------`--------- <br /> ,,,...\:,..„.:%\%\\~ WELLHEAD COMPLETION <br /> w ET Outside: R�Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> S Mile ❑Well Pit ❑Buried ❑Well House <br /> • -------- -.------ ❑Well Pit <br /> S 1 El Other <br /> ❑Buried <br /> 1 Mile • <br /> ❑Other <br /> For temporary borings,provide io I I ion ).,, • CASING(S) <br /> information,a site sketch,and Dia ter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from C) to1.40 ft. ❑Yes lo ❑Yes ❑No ❑Unknown <br /> T Stherber Demolition & Reeavating T <br /> ' Property owner's mailing address if different than well location address indicated abo in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 11415 Valley Dr in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> re, MN 55374 2 of 2 SCREEWOPEN HOLLE/, J/ (/ <br /> WELL OWNER'S NAME/COMPANY NAME Screen from (fJCJ to /t 2'7 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above )(Rods/Drop Pipe ❑Check Valve(s) ❑Debris ElFill ❑No Obstruction <br /> Type of Obstructions(Describe) r"'JCnn..A_ A/ d <br /> Obstructions removed? Xes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present Present,Removed Prior to Sealing ❑Other <br /> If no known,indicate estimated formation log from nearby well or boring. Type drj.. .y,,-,o„t, <br /> /� t� METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> 1....6v 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 °No TN# <br /> GROUTING MATERIAL(S) / <br /> Grouting Material h 0£a.-/1 -am 0 to f C V ft. yards CA, bags <br /> �� from to ft. yards bags j <br /> from to ft. yards bags i <br /> t <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 DrillingCo,. Inc 1691 <br /> Licensee Business Name License or Registration No. <br /> //as v y / 0 - 0-oC() <br /> C 1�€(Aesentative Sigliature Certified Rep.No. Date <br /> • <br /> LOCAL COPY I H 3 8 0 6 8 4 ' <br /> 1 Name of Person Sealing Well or Boring 7....)HE-01434-17 ID#53159 1 11/19R <br /> 1 <br />