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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3921 6 2 <br /> SealCounty Name WELL AND BORING SEALING RECORD Minnlesotang oUnique Well No. <br /> Hennepin Minnesota Statutes,chapter 1031 or W-series No. <br /> (Leave dank I/not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-a Ig.) Date Sealed Date Well or Boring Constructed <br /> Orono 117 23 21 SW #W 41W 12/23/21 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 64 ft. Original Depth ft. <br /> Latitude Longitude <br /> laUIFER(S) STATIC WATER LEVEL <br /> Numerical Street Address or Fire Number and City of Well or Boring Location Single Aquifer ❑Multiaquifer Pheasant <br /> ) l <br /> 2670 haSt Rd ©rOAQN WELL/BORING X Measured Date Measured 12/ 23!21 IIIEstimated <br /> I Water-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. X below ❑above land surface <br /> lines,naiads, <br /> . <br /> ads,,nd buildin. <br /> N CASING TYPE(S) <br /> 111111111111 y( Steel Plastic ❑Tile ❑Other <br /> ��wmkf �Ytt WELLHEAD COMPLETION <br /> INIENIWT. � Outside: ID Pitless Adapter/Unit ❑At Grade Inside: lk Basement Offset <br /> I <br /> Mile ❑Well Pit III Buried ❑Well House <br /> 111111111011 1 <br /> ❑Other ❑Well Pit <br /> S <br /> Buried <br /> I Hulk <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 /> PROPERTY OWNER'S NAME/COMPANY NAME 4 in.from to _ft. ❑Yes ❑No ❑Yes ❑No IC Unknown <br /> RJ Nalene Construction <br /> Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 4464 West Ara Rd in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Sprin6 Park, MR 55384 <br /> SCREEWOPEN HOLE <br /> WELL OWNER'S NAME/COMPANY NAME <br /> Screen from 60 to 64 ft. Open Hole from to ft. <br /> OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above IC Rods/Drop Pipe ❑Check Valve(s) ❑ss Debris ElFill ❑No Obstruction <br /> Type of Obstructions(Describe) drop pipe <br /> Obstructions removed? [)Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present X Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type subme r a I b 1 e <br /> drift 0 64 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> LNo 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) <br /> Grouting Material_ eat Cement from 1 to b4 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 [XNo 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 /> I is true to the best of my knowledge. gt <br /> DON STODOLA WELL DRILLING CO., INC• 1�■A <br /> Licensee Busin Name License or Registration No. <br /> —"" ' 441 l-�r 558 12/23/2 <br /> if Representative Signature Certified Rep.No. Date <br /> LOCAL COPY v <br /> H 92162 Jerry parr <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 17naR <br />