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HE -01434-17 ID# 53159 i I/19H <br />Minneso <br />MINNESOTA DEPARTMENT OF HEALTH Sealing to Well and Boring <br />WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br />Minnesota Statutes, chapter 103/ �r W .*9-1 ori <br />I I 4� Q (l <br />(? 1 1 �1 <br />WELL OR BORING LOCATION <br />County Name <br />ITnn n- <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 />Orono <br />117 <br />I 23 <br />07 <br />1 SF SW 'uS <br />9/2/21 <br />GPS LOCATION — decimal degrees (to four decimal places) <br />n L <br />Depth at Time of Sealing C] � ft. <br />Original Depth ft. <br />Latitude Longitude <br />AQUIFER(S) <br />KI Single Aquifer ❑ Multiaquifer <br />STATIC WATER LEVEL <br />Measured Date Measured) 2 21 E] Estimated <br />3 2 t1. RJ below ❑ above land surface <br />Numerical Street Address or Fire Number and City of Well or Boring Location <br />1390 Rest Point Rdo Orono <br />WELUBORING <br />® Water -Supply Well ❑ Env. Well <br />❑ Temp. Boring ❑ Other <br />Show exact location of well or boring Sketch map of well or borirr��gg <br />in section grid with "X." location, showing props riy <br />CASINGTYPE(S) <br />Steel ❑ Plastic ❑ Tile ❑ Other <br />N 5361 lines, roads,Idbyfldngs. <br />-1--] <br />WELLHEAD COMPLETION <br />Outside: ❑ Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset <br />❑ Well Pit ❑B uried Well House <br />❑ Well Pit <br />< <br />W i E <br />f , T <br />vz Mile <br />—% I <br />T <br />L <br />s <br />❑ Other <br />❑ Buried <br />—t Mile y <br />jo Other f- CAW PACE <br />CASING(S)-- <br />For temporary borings, provide additional location <br />information, a site sketch, and geology on a separate page. <br />Diameter 4 Depth n Set in oversize hole? Annular space initially grouted? <br />3 in. from 1 to Q O ft. ❑ Yes ❑ No ❑ Yes ❑ No Xj Unknown <br />in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />PROPERTY OWNER'S NAME/COMPANY NAME <br />Property owner's mailing address if different than well location address Indicated above <br />in, from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown <br />SCREEN/OPEN HOLE <br />WELL OWNER'S NAME/COMPANY NAME <br />�' <br />Screen from to ---91-4-11. Open Hole from to ft. <br />OBSTRUCTIONS <br />ja Rods/Drop Pipe ❑ Check Valve(s) Debris ❑ Fill ❑ No Obstruction <br />Well owner's mailing address if different than property owners address indicated above <br />1,❑ <br />Type of Obstructions (Describe) drop )tfte <br />Obstructions removed? W Yes ❑ No Describe <br />PUMP <br />Not Pt, Roved Prior to Sealing El Other <br />Present, em <br />❑ resent Pg <br />Type e t pump <br />GEOLOGICAL MATERIAL <br />COLOR <br />Hon <br />FORMATION <br />FORMATION <br />FROM <br />TO <br />If not known, indicate estimated formation log from nearby well or boring. <br />drift <br />O <br />84 <br />METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BOREHOLE <br />® 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 ❑ No TN# <br />GROUTING MATERIAL(S) <br />Grouting Material iiTo A t r Mn n trom--I_ to A4 n. yards_4 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 id 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 />is true to the best of my knowledge. <br />REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING <br />Don Stodola Well Drilling Co Inc 1691 <br />Licensee Business Name p License or Registration No. <br />,/r 553 9/2/21 <br />rtified epresentafive Sign tore Certified Rep. No. Date <br />Jerry Barr <br />LOCAL COPY <br />JH g 6 <br />Name of Person Sealing Well or Boring <br />HE -01434-17 ID# 53159 i I/19H <br />