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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 1 <br /> WELL OR BORING LOCATION WELL AND BORING SEALING RECORD Sealing No. 1. ..,. <br /> County Name Minnesota Unique Well No. <br /> HENNEPIN 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 NKNE'a Sid 11/12/2025 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 35 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 L1 ingle Aquifer ❑Multiaquifer 1 1 +� q G <br /> W ELUBORING ®Measured Date Measured 1 1/12/2 5❑Estimated <br /> 4485 NORTH SHORE DR. ,ORONO,MN s Later-Supply Well ❑Env.Well <br /> Show exact location of Ai SSi614 Sketch map of well or boring <br /> in section grid with"X." location,showing property ❑Temp.Boring ❑Other 26 ft. [lbelow ❑above land surface <br /> lines,roads,and buildings. <br /> N }�� CASING TYPE(S) <br /> ...+ �x r� Li teel Plastic ❑Tile ❑Other <br /> ---'---'--'----'`--'---'--- <br /> Q WELLHEAD COMPLETION <br /> VI - E <br /> T <br /> Outside: [1 Pitless Adapter/Unit ill At Grade Inside: [Basement Offset <br /> 'k Mile ❑Well Pit ❑Buried ❑Well House <br /> 1 <br /> ❑Well Pit <br /> s6 ❑Other <br /> ❑Buried <br /> I I Mile <br /> ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. Diameter 7 Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME q 2 in.from 1 to 31 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 /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> SCREEWOPEN HOLE <br />' .'It,. WELL OWNER'S NAME/COMPANY NAME Screen from 31 to 35 ft. Open Hole from to ft. <br /> OMNI C JST9M UIt DERS LLC OBSTRUCTIONS <br /> Well owner's mailing aoddress iif afferent an property owners address indicated above [Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> DROP PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? I Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Presentn ®Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type JET ET <br /> DRIFT 1 35 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 Q No TN# <br /> pp - GROUTING MATERIAL(S) <br /> / NEAT C 1 <br /> Grouting Material CEMENTfrom to 35 ft. yards bags <br /> d/ <br /> from to ft. yards bags <br /> ) <br /> from to ft. yards bags <br /> 1 <br /> OTHER WELLS AND BORINGS <br /> Other unsealed and unused well or boring on property? ❑Yes at 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 BfBusiness ame License or Registration No. <br /> ., I,+e_ 558 11/12/25 <br /> r-di 7d'epresent-''Signature Certified Rep.No. Date <br /> LOCAL COPY H 4 2 1 6 1 Nam JEof R RPerson Sealing8A R WRor Boring <br /> HE-01434-17 ID#53159 ; 71/InR <br />