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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 419762 <br /> WELL AND BORING SEALING RECORD <br /> County Name Minnesota Na Unique Well No. <br /> H E N N E P I N Minnesota Statutes,chapter 1031 orrW-series .No Ln not kna <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) Date Sealed Date Well or Boring Constructed <br /> ORONO 117 23 209 Sit, SW SE 7$2B/2O25 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 74 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 E, Single Aquifer ❑Multiaquifer <br /> ,:, } 1 ry CASCO <br /> C gq� iT y Measured Date Measured 2 Estimated <br /> ��- J�JJ Lrl�• �IWA1A.rA�A�1"Ii '�� wELL/BORING ® 7 2�3 �� ❑ <br /> ` E Water-Supply Well ❑Env.Well <br /> Show exact location ng Sketch map of well or boring <br /> in section grid with"X" location,showing property ❑Temp.Boring ❑Other 34 ft. je below ❑above land surface <br /> lines,roads,and buildings. <br /> N CASING TYPE(S) <br /> ]Steel ❑Plastic ❑Tile ❑Other <br />�'. ---'--- '----'-`--------- WELLHEAD COMPLETION <br /> w ET ' Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: SEI Basement Offset <br /> ' + ❑Well Pit ❑Buried Well House <br /> h Mile ❑❑ <br /> 1 r Well Pit <br /> 'F ❑Other Q <br /> S \\ ❑Buried <br /> ..fI 1 Mile I ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separat page. Diameter Depth 7 n Set in oversize hole? Annular space initially grouted? <br /> PROPERTY�ppOggW^yy NjE7R'S NAME/COMPANYyi��sP NAMEtY �t 3 in.from 1 to r 0 ft. ❑Yes ❑No ❑Yes ❑No 11 Unknown <br /> WVV0DAL✓E HOMES LLC <br /> Propel`ty 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 �f <br /> WELL OWNER'S NAME/COMPANY NAME Screen from 70 to r4 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address If different than property owner's address indicated aljpve ]Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> U 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 Lii Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. �!} Type JET <br /> DRIFT 1 0 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'ZJ No TN# <br /> GROUTING MATERIAL(S) <br /> Grouting Material NEAT <br /> +AT C M E i'9 T from to 7 4 ft. yards 4 bags <br /> from to ft. yards bags <br /> from to ft. yards bags <br /> OTHER WELLS AND BORINGS <br /> it <br /> Other unsealed and unused well or boring on property? ❑Yes It 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. ,IdC. 1691 <br /> Licensee Busiiness Name License or Registration No:.,_ <br /> 558 7/28/25 <br /> e ied Representative Signature Certified Rep.No. Date <br /> LOCAL COPY H <br /> 419762 ����� ���� <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />