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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H401694 <br /> County Name No. <br /> WELL AND BORING SEALING RECORD MinnSealesota Unique Well No. <br /> liENNEPIN Minnesota Statutes,chapter 1031 or W-series No. <br /> (Leave blank if.known) <br /> Township Name Township No. Range No. Section No. Fraction(sm..—+lg.) Date Sealed Date Well or Boring Constructed <br /> ORONO 117 23 17 tW WSE lk 5/24/23 <br /> - <br /> I GPS LOCATION—decimal degrees(to four decimal places) 226 <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 I]Single Aquifer ❑Multiaquifer 5/2 4 2 3 <br /> 2171 #�ADYWOOD r ear WELL/BORING Measured Date Measured ❑Estimated <br /> AsiA• ' <br /> - ]Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring 5.5391 Sketch map of well or boring 40 <br /> in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. ,XA below ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> NSs <br /> Steel ❑Plastic ❑Tile ❑Other <br /> ---'-- WELLHEAD COMPLETION <br /> W —.E <br /> T ii.,, <br /> Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: g Basement Offset <br /> h Mile ❑Well Pit ❑Buried ❑Well House <br /> ' S-r r- <br /> - ❑Well Pit <br /> ❑Other <br /> ❑Buried <br /> 1 Mile <br /> ❑Other <br /> For temporary borings,provide additional loca . CASING(S) <br /> information,a site sketch,and geology on a se..ate'' . Di eter De h. Set in oversize hole? Annular space initially grouted? <br /> P PERTY OWNER' ME COMPANY NAME in.from 1 to ft.� A ii i`iSt i ❑Yes ❑No ❑Yes ❑No ]Unknown <br /> Property owner's mailing address if different than wel - ion address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEWOPEN HOLE <br /> 226 <br /> Screen from "�" to ft. Open Hole from to ft. <br />• WELL OWNER'S NAME/COMPANY NAME ' <br /> JACQUELIN ROBERTSON OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above Fl Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br />. DROP PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present g Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. ey Type JET PUE4P <br /> ' METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,-OR CASING AND BORE HOLE <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 /> NAT CE E r 1 226 5 <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 /> DON STODOLA WELL DRILLING CO. ,iNC. 1691 <br /> Licensee Business Name License or Registration No. ' <br /> � p 55 5/24/23 <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY H 401 0 04 J E R Y B A R <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />