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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H I 4 8 <br /> 0 5 8 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. V 8 <br /> County Name Minnesota Unique Well No. <br /> l E N N£PIN Minnesota Statutes,chapter 1031 or W-series No. <br /> (Leave dank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—.lg.) Date Sealed Date Well or Boring Constructed <br /> ORONO 117 23 07 IENESE '. 11/27/23 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 85 ft. Original Depth ft. <br /> Latitude Longitude <br /> AOUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location 4 Single Aquifer ❑Multiaquifer <br /> 1301 NORTH ARM OR. ,MOUND,MN • WELL/BORING ®Measured Date Measured 11/27/23 ❑Estimated <br /> f Water-Supply Well ❑Env.Well 71 <br /> Show exact location of well or boring 5536 ketch map of well or .ring <br /> in section grid with"X." location,showing prop:ty ❑Temp.Boring ❑Other ft. ®below ❑above land surface <br /> N in-s, and buildin s. CASING TYPE(S) <br /> r4.) <br /> die_ [Steel ❑Plastic ❑Tile ❑Other <br /> F <br /> ---'------ <br /> '---•--`------ <br /> `--- WELLHEAD COMPLETION <br /> W E <br /> T <br /> r <br /> a utside: x Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'h Mile Z.. ❑Well Pit ❑Buried ❑Well House <br /> ---, r- —.1 <br /> 1 <br /> iii X 7- <br /> ❑Other ❑Well Pit <br /> s ❑Buried <br /> 1 Mile g,� <br /> hu ❑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 /> PROPERTY OWNER'S NAME/COMPANY NAME A in.from 1 to 8 1 ft. ❑Yes ❑No ❑Yes ❑No ®Unknown <br /> SABRINA VLECY <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 fi <br /> WELL OWNER'S NAME/COMPANY NAME Screen from _81 to 8 5 ft. Open Hole from to ft. <br /> SABRJ A VLEC1 OBSTRUCTIONS <br /> Well owner's mailing address if different than properly owner's address indicated above jRods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) DROP PIPE <br /> Obstructions removed? QYes ❑No Describe <br /> PUMP . <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO Not Present jj Present,Removed Prior to Sealing❑ u ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. C Type SUBMERSIBLE <br /> DRIFT 1 85 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> k 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 ANo TN# <br /> GROUTING MATERIAL(S) <br /> NEAT CEMENT 1 85 8 <br /> Grouting Material from to ft. yards 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 /> 558 1I/27/23 <br /> erti Representative Signature Certified Rep.No. Date te <br /> LOCAL COPY ' H. 405888 JERRY BARR <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />