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'r• MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 415603 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD . Sealing Nounique Well No. <br /> County Name <br /> r HENNEPIN Minnesota Statutes,chapter 1031 oraW seriesNoo. <br /> Township Name Township No. Range No. Section No. Fraction(sm.-.lg.) Date Sealed Date Well or Boring Constructed <br /> ORONO 118 23 27 S6diS 'a SF 2/2'SI C}25 . <br /> GPS LOCATION-decimal degrees(to four decimal places)Latitude Longitude 4 <br /> Depth at lime of Sealing 1 2 7 ft. Original Depth ft. <br /> AQUIFER(S) STATIC WATER LEVEL ` <br /> Numerical Street Address or Fire Number and City of Well or Boring Location X Single Aquifer ❑Multiaquifer <br /> 900 BROWN RD,N.. ,LONG LAKE,MN WELL/BORING Ej Measured Date Measured 2/2 5/25 ❑Estimated <br /> CC tis ar XI Water-SupplyWell ❑Env.Well <br /> Show exact location ofit5 3514 Sketch map of well or boring 7 2 <br /> in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. elow ❑above land surface <br /> lines,roads,and buildings.N CASING TYPE(S) <br /> L 74 <br /> at Steel ❑Plastic ❑Tile ❑Other <br /> .________a_--_._.-___,__. _ WELLHEAD COMPLETION <br /> W E C f`„"` <br /> __ ____ ___t-_ T � Outside: A Pitless Adapter/Unit El At Grade Inside: ❑Basement Offset <br /> 'h Miie2 : L ❑Well Pit ElBuried ❑Well House <br /> --- -- I .p ❑Well Pit <br /> S 1 t ❑Other ❑Buried <br /> 1-1 Mile—I y"S'',,,, <br /> ❑Other <br /> For temporary borings,provide additional loc ion —-r --• CASING(S) <br /> information,a site sketch,and geology on a s parate page. Diameter t Depth f !1 A Set in oversize hole? Annular space initially grouted? <br /> PRQp TY,pWr al fM /WMPANY NAME 4 in.from I to i( 1 9 ft. ❑Yes ❑No ❑Yes El No �j Unknown <br /> Property owner's mailing address if different than well location address indicated above in.from ' to r) ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> /in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEN/OPEN HOLE �,b• _ <br /> WELL OWNER'S NAME/COMPANY NAME Screen from to `�f ft., Open Hole from - to <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above XI Rods/Drop Pipe ElCheck Valve(s) ❑Debris ` El Fill ❑No Obstruction " <br /> DROP PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? f j Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO • <br /> FORMATION ❑Not Present resent;Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. OS S <br /> DRIFT <br /> tt �y 127 Type , <br /> 1 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> ANo 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 C No TN# <br /> GROUTING MATERIAL(S) . +�7� ' <br /> Grouting Material NEAT C E N E N 1from 1 to.2 7 ft. yards la bags ' <br /> l <br /> • <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 .c 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. . I691, . <br /> ' ;licensee Business N e - License or Registration No. , - <br /> _.- 2I2512S <br /> _ <br /> e Repre,entative Sigfia e" ,Certified Rep.No. Date <br /> LOCAL COPY <br /> " 415603 JERRY BARR <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />