12-13-2021 Well & Boring Sealing Record

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HE -01434-17 ID# 53159 a isn MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring Sealing No. WELL AND BORING SEALING RECORD Minnesota Unique Well No. Minnesota Statutes, chapter 1031 r W_SeerieswNo. HWELL 392191 OR BORING LOCATION County Name i + enne in Township Name Township No. Range No. Section No. Fraction (sm. -r Ig.) Date Sealed Date Well or Boring Constructed zona 117 23 07 ,ANN ESN 140 12/13/21 GPS LOCATION — decimal degrees (to four decimal places) Latitude Longitude Depth at Time of Sealing 140 ft. Original Depth ft. AQUIFER(S) [NSingle Aquifer ❑ Multiaquifer STATIC WATER LEVEL 1 *f / f / �f • 1 Measured Date Measured i G i 1. ❑ Estimated 7 ft. �] below E] above land surface Numerical Street Address or Fire Number and City of Well or Boring Location 94CF, North Arm Dr, Orono WELUBORING [?FWater-Supply Well ❑Env. Well El Temp. Boring ❑ Other Show exact location of well or boring Sketch map of well or bating in section grid with "X" location, showing property N lines, roads, and buildings. y CA$INGTYPE(S) ❑Steel Cyt � Plastic E] Tile ❑ Other I l I l W t l e ' i5P 'k Mile r . r 1 I I I I o� S �1 Mile WELLHEAD COMPLETION Outside: Xj Pitless Adapter/Unit ❑ At Grade Inside: ❑ Basement Offset ❑ Well Pit ❑ Buried Well House o Well Pit El Other ❑ Burled ❑ Other For temporary borings, provide additional location CASING(S) information, a site sketch, and geology on a separate page. Diap+eter 1 Depth Set in oversize hole? Annular space initially grouted? 't In. from to 130 ft. ❑ Yes ❑ No ❑ Yes ❑ No A Unknown in. from to ft. ❑ Yes ❑ No ❑ Yes ❑ No ❑ Unknown P OPER OWNE ' NAMEICOMPAN ME Zander Romes �(ZVNnAe.V Property owners mailing address if different than well location address indicated above 10300 10th Ave No Plymouth, MN 55441 in. from to h. ❑Yes ❑ No El Yes ❑ No El Unknown SCREEWOPEN HOLE Screen from 130 to 140 R. Open Hole from WELL OWNER'S NAME/COMPANY NAME OBSTRUCTIONS ❑ Rods/Drop Pipe ❑ Check Valve(s) ❑ Debris ❑ FIII No Obstruction Well owner's mailing address 9 different than property owners address indicated above Type of Obstructions (Describe) Obstructions removed? ❑ Yes ❑ No Describe PUMP Not Present ❑ Present, Removed Prior to Sealing Other g ❑ - Type GEOLOGICAL MATERIAL COLOR HARDNESS OR FORMATION FROM TO If not known, indicate estimated formation log from nearby well or boring. drift 0 1 4 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS, OR CASING AND BORE HOLE No Annular Space Exists ❑ Annular Space Grouted with Tremfe 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) �+ n Grouting Material Neat Cement from 1 to 140 ft. yards l2 bags from to ft. yards bags from to ft. yards bags OTHER WELLS AND BORINGS yy Other unsealed and unused well or boring on property? E] Yes L1 No How many? LICENSED OR REGISTERED CONTRACTOR CERTIFICATION 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. REMARKS, SOURCE OF DATA, DIFFICULTIES IN SEALING Don 3todola, Well Drilling Co Inc 1691 Licensee Business N e License or Registration No. 558 12/1.3/21 entified Repiesentaffve Signatu a Certified Rep. No. Date Jury Bahr LOCAL COPY H I ;? ,I Name of Person Sealing Well or Boring HE -01434-17 ID# 53159 a isn