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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H ')0 1 0 2 <br /> Sealin No.County Name WELL AND BORING SEALING RECORD Minnesota Unique Well No. <br /> ,- Minnesota Statutes,chapter 103I or W-series No. <br /> TTennep 3 (Leave lank if not known) <br /> n <br /> Taliyffship Name ' Township No. Range No. Section No. Fraction(sm.-*lg.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 20 NW 6/8/22 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 53 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 ►'Single Aquifer ❑Multiaquifer 80 Garment St O� 5 C 393 WELL/BORING Z Measured Date Measured ! ❑Estimated <br /> 2�# ] 'T L X Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or boring 7 ft.❑Temp.Boring ❑Other below ❑above land surface <br /> in section grid with"X." _ location,showing property <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> Steel ❑Plastic ❑Tile ❑Other <br /> j 77 <br /> f's WELLHEAD COMPLETION <br /> W E '�'.°"'e, ,"-+-,"a--+.,.�,r�-.---- ,.., -...-�.�, <br /> T Outside: [ Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile d ❑Well Pit ❑Buried ❑Well House <br /> 1 I i , ❑Other <br /> ❑Well Pit <br /> t <br /> 3 ❑Buried <br /> I1 Mile <br /> ❑Other <br /> For temporary borings,provide additional location •---- - CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> 4Fti0I RTY OvIF�R S AaMIc O ANY NA E 4 in.from I to 49�" ft. ❑Yes ❑No ❑Yes ❑No ❑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 /> 70 Florence Dr . <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Excelsior, NN 55331 <br /> SCREEN/OPEN HOLE q <br /> Screen from "` "to 3 ft. Open Hole from to ft. <br /> WELL OWNER'S NAME/COMPANY NAME <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above [ Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) Drop Pipe <br /> Obstructions removed? ]Yes ❑No Describe <br /> PUMP <br />-. GEOLOGICAL MATERIAL COLOR HARDNESS OR FORMATION FROM TO ❑Not Present Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type submersible <br /> drift 0 53 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> M 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 X No TN# <br /> GROUTING MATERIAL(S)Grouting Material Neat Gee n t from 1 to 53 ft. yards 5 bags <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 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 1691 <br /> Licensee Business Name License or Registration No. <br /> �� ► <br /> 558 <br /> r <br /> erti epr�esentativeignatuie Certified Rep.No. Date <br /> LOCAL COPY <br /> " 3 9 5 1 0 2 Jerry Barr <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />