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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Sealing Minnesota <br /> N Well and Boring H 3 C 5 1 11 <br /> County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> /� <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> Tennep i n (leave blank it not known) <br /> CerRA-'^/ Township No. Range No. Section No. Fraction(sm.—r lg.) Date Sealed Date Well or Boring Constructed <br /> AftVaTTt 117 23 20 SE'ASE N 6/14/22 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> 1 <br /> Depth at Time of Sealing ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location X]Single Aquifer ❑Multiaquifer 6/14/22 <br /> + <br /> 2700 Cosco Rd, Navarre CG�iA ELL/BORING Measured Date Measured 6/ 4/ ❑Estimated <br /> G LI Rd !,r PtJ J 3 Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or boring 76 <br /> in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. below ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> •«K- X Steel ❑Plastic ❑Tile ❑Other <br /> '--'--- ---'--- jR�, WELLHEAD COMPLETION <br /> w - ET te' <br /> Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: X Basement Offset <br /> j Mile f Well Pit ❑Buried WellHouse <br /> hPill <br /> ❑❑ <br /> s I V Pit <br /> 1 ❑ <br /> Well <br /> ) i ill Other <br /> I Buried <br /> 1 Mile <br /> at ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter Depth <br /> Set in oversize hole? Annular space initially grouted? <br /> PriiiTYYVIVARi itiAECOMPANY NAME 2 in.from 1 to f O/ ft. ❑Yes ❑No ❑Yes ❑No Unknown <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 ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPENHOLEE� <br /> Screen from 107 to 111 ft. Open Hole from to ft. <br /> WELL OWNER'S NAME/COMPANY NAME <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above IX Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) <br /> Rod8 <br /> Obstructions removed? gYes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present A Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type stroke pump <br /> drift 0 111. METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> ,[J 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 2]No TN# <br /> ' GROUTING MATERIAL(S) �+ <br /> Grouting MatL�rral Neat Cemen yy from 1 to 111 , yards 3 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 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 /> Don Stodola well Drilling Co 1691 <br /> Licensee Busines ame License or Registration No. <br /> 558 6/14/22. <br /> Ce dfert ed Representative Signature Certified Rep.No. Date <br /> Jerry Barr <br /> LOCAL COPY H .) (I 1 1 1�- -�- --� .�r.. Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />