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FH of 405089 MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring WELL OR BORING LOCATION Seating•No. H County Name WELL AND BORING SEALING RECORD Mlnnesota Unique Well No. Minnesota StatutesBenne in ,chapter 1031 or W-series No. ..�.(Leave blank if not known) Township Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed f ,,,� 1 ;,..,.. Date Well or Boring Constructed ` Orono 117 23 09 • X-W S'ti / `-' ',- `'. �,_- GPS LOCATION-decimal degrees(to four decimal places) r'""'{ ' Depth at Time of Sealing ft. Original Depth ft. • Latitude Longitude - NUIFER(S) STATIC WATER LEVEL Numerical Street Address or Fire Number and City of Well or Boring Location ASingle Aquifer'❑Multiaquifer An / #// . 74, North. Shore- Orono WELLBOSING ISI Measured Date Measured d ❑Estimated 3105 Drive ❑Water-Supply Well E Well // �R Show exact location of well or boring Sketch map of well or boring in section grid with"X." 2 1 location,showing property ❑Temp.Boring ❑Other La') ft. .below ❑above land surface 55391 lines,roads,an. •uildings. , N CASING TYPE(S) q1 Steel ❑Plastic ❑Tile ❑Other ,, -.---'---- iil !!!!llWEELLHEAD COMPLETION r__ r__- Outside:XPitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset / Mile ❑Well Pit ❑Buried ❑Well House ❑Other ❑Well Pit S # i s 1, ❑Buried �£.ya I 1 Mile— I - :` r ( L'" ❑Other -For temporary borings,provide additional location i II..., • CASING(S) '' information,a site sketch,and geology on a separate page. - Drier Dept, ..!ly, ,,,,,, Set in oversize hole? Annular space initial) grouted? PROPERTY OWNER'S NAME/}COMPANY NAME in.from / to e > Elft. ❑Yes ❑No ❑Yes No Unknowny Wood4 lie Rtti i€tprc1 Inc_ . Property owner's mailing address if different than well location address indic fed above in.from to f ft. -Y . ❑Yes ❑No ❑Yes ,,, ❑No ❑Unknown ' • 6117 Blue Circle Drive . • #1 0# in.from to ft. ❑Yes ❑No ❑Yes Q No ❑Unknown Minnetouka,Mn. 55343 SCREEN/OPENHOLE WELL OWNER'S NAME/COMPANY NAME Screen from ... to ft. -Open Hole from to ft. .3 OBSTRUCTI.. { i_:,:-^ , _` _ 1I. _ Well owner's mailing address if different than property owner's address indicated above • XRod-Drop Pipe ❑Check Valve(s) ❑Debris '❑Fill .❑No Obstruction Type of Obstructions(Describe)ri► - Obstructions removed? Ji4.Yes ❑No Describe I PUMP HARDNESS OR GEOLOGICAL MATERIAL COLOR FORMATION FROM TO ❑Not Present Presents.Remo ed Prior to Sealing ❑Other If not known,indicate estimated formation log from nearby well or, QCing. Type• 1 . +++��111(5 F . METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE XNo Annular Space Exists ❑Annular Space Grouted with Tremie Pipe ❑Casing Perforation/Removal Casing Diameter in.from to ft. ❑Perforated ❑Removed in.from to ft. ❑Perforated ❑Removed - Type of Perforator - - VARIANCE Was a variance granted from the MDH for this well? ❑Yes,,.❑No TN# GROUTING MATERIAL(S) �j' ''.. ' Grouting Material/)e f /1 ('13 / to q ft. . yards O bags I from to ft. yards bags - from to ft. yards bags • OTHER WELLS AND BORINGS Other unsealed and unused well or boring on property? ❑Yes X No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION 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 is true to the best of my knowledge. �r! ma�qy, r�a p��y sA WELL DRILLING ��ss INC h•�i r- Licensee Business. ame License or Registration No. y r 558 /).// rtif edl 'Representative Signature Certified Rep.No. Date LOCAL H _4:0 5 Q 8 9w r �: - el ter " Name of Person Sealing Well or Er . HE-01434-17 ID#53159 • - 11/19R