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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 421682 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. <br /> County Name Minn sotasUni ue Well No. <br /> H E N N E P I i Minnesota Statutes,chapter 1031 or(peeve Monk r na knavo <br /> o. <br /> Township Name Township No. Range No. Section No. Fraction(sm.-a lg.) Date Sealed Date Well or Boring Constructed <br /> ORONO 117 23 07 NENE :eta' 11/12/2025 <br /> GPS LOCATION-decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 78 ft. Original Depth ft. <br /> Latitude Longitude <br /> AQUIFERS) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location L Single Aquifer ❑Multiaquifer 1�# <br /> 4485 85 SHORE D e r ttRONO.MN WELL/BORING easured Date Measured i/12!2 ❑Estimated <br /> �i NORTHSHORE V O [Water-Supply Well ❑Env.Well <br /> Show exact location of 45364 Sketch map of well or boring ❑ Boring ft. ®below <br /> in section grid with"X." location,showing property Temp. ❑Other ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> i - -- S 11 tikE Pla <br /> Steel El Plastic ❑Tile El Other <br /> WELLHEAD COMPLETION <br /> W , ' r r ET <br /> Outside: itless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile K ❑Well Pit ❑Buried ❑Well House <br /> 1:1 ❑Well Pit <br /> 1 ❑Other <br /> s ❑Buried <br /> 1 1 Mile -I <br /> ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separat ge. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from to 74 ft. ❑Yes ❑No Li Yes ❑No A 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 /> SCREEWOPEN HOLE` T <br /> Screen from 74 to f 8 ft. Open Hole from to .,ft. <br /> WELL OWNER'S NAME/COMPANY NAME <br /> OMNI CUSTOM BUIfDERS 1 LC OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above A Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) DROP PIPE <br /> Obstructions removed? LitYes ❑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. Type S U BME R S I BL E <br /> DRIFT 1 78 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 [ Jo TN# <br /> GROUTING MATERIAL(S) phry�tp+ pp��tt 7 <br /> Grouting Material NEAT CEMEN rom 1 to 78 ft. yards bags <br /> e 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 ❑ Jo 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 ame License or Registration No. <br /> 558 11/12/25 <br /> d epres Signature Certified Rep.No. Date <br /> LOCAL COPY H 4 21682 JERRY BARR <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 tt/t9R <br />