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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 405041 <br /> WELL AND BORING SEALING RECORDNo. <br /> County Name Minnlesota Unique Well No. <br /> or W-series No. <br /> E P IN Minnesota Statutes,chapter 1031 (Laaoo dank i no,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 NENEWE'A 9/8/23 <br /> GPS LOCATION—decimal degrees(to tour decimal places) 228 <br /> Depth at Time of Sealing ft. Original Depth ft. <br /> Latitude Longitude <br /> /� <br /> AQUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring L�8AO®Single Aquifer ❑Multiaquifer <br /> 941 NORTH <br /> ARM �Jt. ©YND,MN. 3 L/BORING Measured Date Measured 9/8/23 ❑Estimated <br /> 1 #i) A V!J •I ater-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or boring <br /> in section grid with"X." . location,showing property ❑Temp.Boring ❑Other ft. ®below ❑above land surface <br /> N 4 �l• <br /> ines,roads,and buildings. CASING TYPE(S) <br /> t <br /> rF f <br /> E Steel pg Plastic ❑Tile ❑Other <br /> iik - 44� WELLHEAD COMPLETION <br /> W ET <br /> T •utslde: QPftless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> %Mi- ❑Well Pit ❑Buried ❑Well House <br /> iSor <br /> -- -----r-s- ?--- l <br /> ❑Other <br /> ----- ❑Well Pit <br /> ❑Buried <br /> i Mile ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. ' Diameter Depth'q Set in oversize hole? Annular space initially grouted? <br /> R'PRciriya S plyju)�/�o grtly_rE 4 in.from I tom ft. ❑Yes ❑No El 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 /> SCREEN/OPEN HOLE <br /> 220 A a�Q <br /> 22Si <br /> Screen from to ft. Open Hole from to ft. <br /> WIl ; SfJAMF,dri Y ti OBSTRUCTIONS <br /> Well owner's mailing address it different than property owner's address indicated above 4Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill '❑No Obstruction <br /> DROP PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? Z]Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present El!PPrressent,lpRemooved Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. �i Type SUBMERSIBLE <br /> MICIF T 1 22tl METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> X 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 pi No TN# <br /> GROUTING MATERIAL(S) CEMENT 1 a�q 17 <br /> 22$ 17 <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 Other unsealed and unused well or boring on property? ❑Yes A 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+tr No. <br /> fd yW 556 9/8/23 <br /> rt `,Representative Signature Certified Rep.No. Date <br /> LOCAL COPY H 405 0 41. JERRY BARR <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 ivign <br />