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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and BoringW Hng No. e p <br /> CountyELL OR BORING LOCATION SealWELL AND BORING SEALING RECORD Name Minntesota Unique Well No. �? <br /> Minnesota Statutes,chapter 1031 oBBW series No. <br /> AtihitaINve blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed <br /> CRUNO 118 23 25 S'i 3 SEA 9/26/22 <br /> GPS LOCATION-decimal degrees(to four decimal places) Depth at Time of Sealing 354 <br /> . ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire <br /> �+Number <br /> RD. ,and City of Well or Boring Location ®Single Aquifer III Multiaquifer <br /> J25 liOLLANDER Oeiur O, AA WELL/BORING ®Measured Date Measured 9/26/22 ❑Estimated <br /> r Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring 53391 Sketch map of well or boring <br /> in section grid with"X." location,showing property ❑Temp.Boring ❑Other 154 ft. ®below ❑above land surface <br /> lines,roads,and buildings. <br /> N a r CASING TYPE(S) <br /> j]Steel ❑Plastic ❑Tile ❑Other <br /> "-"' T WELLHEAD COMPLETION <br /> W E I <br /> Outside: ®Pitless Adapter/Unit III At Grade Inside: Ill Basement Offset <br /> Mile -. ❑Well Pit ❑Buried ❑Well House <br /> - (. <br /> ❑Other ❑Well Pit <br /> S ❑Buried <br /> 1 Mile ❑Other <br /> For temporary borings,provide additional location CA NG( <br /> information,a site sketch,and geology on a separat 3 Dia Depth Set in oversize hole? Annular space initially grouted? <br /> PRCrI L QVy kR'S NA.ME 9APANY NAME . in.from to ft. LI Yes El No ❑Yes IA No ®Unknown <br /> Property owner's mailing address if differentr than well locatio in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from ,to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEWOPEN HOLE <br /> WELLtaOWN�ER'S_NAME/COMPPANYiNAME wI+q� �+ a,S=t a ty�« Screen from to ft. Open Hole from to ft. <br /> JEROME & CHARLOTTE GOLINVAUX OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above ❑Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill t No Obstruction <br /> 325 HOLLAN HER RD. Type of Obstructions(Describe) <br /> ORONO, t N 55391 <br /> Obstructions removed? ❑Yes ❑No Describe <br />�' <br /> '. -PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present Present,Removed Prior to Sealing <br /> FORMATION ® ❑ III Other <br /> I If not known,indicate estimated formation log from nearby well or boring. 354 <br /> C g Type <br /> -'x }-L i' 354 <br /> 1 1 ,MyE�THOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> IA 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 /> r --- NEAT CE :ENT 1 354 40 <br /> Grouting Material from to ft. yards 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 ❑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 /> • <br /> DON STODOLA WELL. CO <br /> 1692. <br /> Licensee Business Name License or Registration No. <br /> edified Representative Signature Certified Rep.No. Date <br /> JL.ftAi DAM( <br /> LOCAL COPY H 3 9 6 9 8 8 Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 ti/tsR <br />