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HE -01434-17 ID# 53159 11/191`1 <br />MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring <br />Sealonry <br />WELL AND BORING SEALING RECORD Minnleso a UNnique Well No. <br />Minnesota Statutes, chapter 1031 or W-sse„i es No. <br />H 381599 <br />mBORING LOCATION <br />OELL <br />T-Torinnain <br />Township Name <br />Township No. <br />Range No. <br />Section No. <br />Fraction (sm. - Ig.) <br />Date Sealed <br />Date Well or Boring Constructed <br />n <br />lfl tl "'M <br />417121 <br />GPS LOCATION – decimal degrees (to four decimal places) <br />LatitudLongitude <br />e <br />Depth at Time of Sealing 19 ft. <br />Original Depth ft. <br />AQUIFER(S) <br />Single Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />Measured Date Measured 1) �! `� El Estimated <br />�ft.] below ❑ above land surface <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />q Crystal Place Orono <br />LLBORING <br />19 Water -Supply Well ElEnv. Well <br />E]Temp. Boring . ❑ Other <br />Show exact location of well or boring Sketch map of well or boring <br />in section grid with "X." location, showing property <br />lines, roads, and buildings. <br />N i 1 � <br />--- --- -- ---L------ <br />CASINGTYPE(S) , <br />® Steel ❑ Plastic ❑ Tile ❑ Other <br />i--- --i--- --- L - ---a <br />WELLHEAD COMPLETION <br />W , ET �. <br />4--- --; 1- -- ---f-- <br />'k Miley <br />S 1 <br />G <br />I— —t Mneme �r{__� <br />Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset <br />Well Pit Buried Well House <br />[ El <br />nn <br />❑ Well Pit <br />E] Other <br />❑ Buried <br />El Other <br />CASING(S) <br />For temporary borings, provide additional location <br />infprmation, a site sketch, and geology on a separate page. <br />Diameter Depth Set in oversize hole? Annular space initially grouted? <br />_ in. from to 1€16 ft. E] Yes E] No ❑ Yes ❑ No Unknown <br />PR PERTY-OWNER'S NCO PANY NAME <br />LaCZAA 1* <br />1-1 <br />Property dwner`smaili adKell diltere t an weu wcatio address Indicated above <br />in. (tom to ft. ❑ Ye5 ❑ No ❑Yes ❑ No ❑ Unknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />SCREEN/OPEN HOLE <br />Screen from to---190—ft. Open Hole from to ft. <br />WELL OWNER'S NAME/COMPANY NAME <br />OBSTRUCTIONS <br />❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ Fill EX 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 />[R Not Present ❑ Present, Removed Prior to Sealing ❑ Other <br />Type <br />GEOLOGICAL MATERIAL <br />COLOR <br />HARDNESS OR <br />FORMATION <br />FROM <br />TO <br />If not known, 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 />[X 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 [:ro TN# <br />GROUTING MATERIAL(S) <br />Grouting Material tgeat Cerleent from_ to--j–W ft. yardsST 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 gJ No 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 Stociola Well Company 1691 <br />Licensee Business Name License or Registration No. <br />4/7/21 <br />esirtif6d'R %sen five $!g Certified Rep. No. Date <br />Jerry Barr <br />LOCAL COPY <br />H ( <br />5 .. J 9 <br />Name of Person Sealing Well or Boring <br />HE -01434-17 ID# 53159 11/191`1 <br />