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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 9 21 6 <br /> County Name WELL AND BORING SEALING RECORD M SealingNo. <br /> Well No. <br /> Hennepin Minnesota Statutes,chapter 1031 or W-series No. <br /> (Leave dank H not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 21 SHAME VW 12/23/21 <br /> GPS LOCATION-decimal degrees(to four decimal places) tt <br /> Depth at Time of Sealing 63 <br /> ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location ❑isingle Aquifer ❑Multiaquifer 1 <br /> 2670 Pheasant Rd Orono, Moa WELL/BORING X Measured Date Measured 1 21 ❑Estimated <br /> I Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch mapi,of well or borin. 17 <br /> x <br /> in section grid with"X." location,shi.wing propert ❑Temp.Boring ❑Other ft. rJ below ❑above land surface <br /> lir,r ad6,-and bu'.',.s. <br /> N ;, - CASING TYPE(S) <br /> .- <br /> �` �)i" I Steel ❑Plastic ❑Tile Li Other <br /> - t---------------- -.- e WELLHEAD COMPLETION <br /> w E <br /> Outside: ❑Pitless Adapter/Unit El At Grade Inside: I Basement Offset <br /> 'h Miledill6 El Well Pit ❑Buried ElWell House <br /> -- -r - -- 1 <br /> ❑Other ❑Well Pit <br /> S 0 Buried <br /> 1----t Mile <br /> El Other . <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diater 1 Depte Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from to ft. ❑Yes ❑No ❑Yes ❑No X Unknown <br /> kJ Yaiek Construction <br /> Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes El No ❑Yes 0 No ❑Unknown <br /> 4464 West Arm Rd <br /> Spria Park, MN <br /> SCREENroPENHOLE <br /> WELL OWNER'S NAME/COMPANY NAME Screen from to 63 ft. Open Hole from to ft. <br /> 55384 OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) I Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) dirt gravel <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO I Not Present ❑Present,Removed Prior to Sealing ❑Other <br /> FORMATION <br /> Iffnot jknown,indicate estimated formation log from nearby well or boring. j� Type <br /> drift 0 63 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> FNo 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 IN No TN# <br /> GROUTING MATERIAL(S) h <br /> Grouting Material Neat Cement from to 63 tyards 3 bags <br /> 9 <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? El Yes X 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 /> DOA STODOLA WELL DRILLING CO., INC. 1691 <br /> Licensee Business Name or Registration No. <br /> / ssa 12/28/2 <br /> C ted epresentative Signature Certified Rep.No. Date <br /> LOCAL COPY H 3 9 216 9 Jerry Barr <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19f <br />