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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring '„I �] <br /> County Name WELL AND BORING SEALING RECORD <br /> MinnlesotaeUnique Well No. p <br /> y� Minnesota Statutes,chapter 1031 or W-series No.avelank if not known) <br /> Re n it e p i (Le b <br /> Township Name Township No. Range No. Section No. Fraction(sm.—'lg.) Date_Sealed Date Well or Boring Constructed <br /> Orono 117 23 041 NIeNg St4 130 7/20/22 7/20/22 <br /> GPS LOCATION—decimal degrees(to four decimal places) 130 <br /> Depth at Time of Sealing 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 rA Single Aquifer ❑Multiaquifer # e� <br /> Lakeview <br /> Pkwy� Orono <br /> ���� WELL/BORING Measured Date Measured 30 l ® timated <br /> 610 ®Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or boring Temp. 130 <br /> BoringOther ft. <br /> in section grid with"X." location,showing property ❑ ❑ IC below ❑above land surface <br /> N lines,roads,and bldings. CASING TYPE(S) <br /> I <br /> -+� f" ITO CASING <br /> ❑Steel ❑Plastic ❑Tile ❑Other <br /> ez <br /> - <br /> --`------`--- �,' WELLHEAD COMPLETION <br /> w 1 E F � <br /> _ T Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> .. .,,,mow I <br /> 2 r <br /> } ❑Well Pit ❑Buried ❑Well House <br /> *-- <br /> __ i '7.: ❑Other ❑Well.Pit <br /> S ,,,,,,,. ❑Buried <br /> I 1 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 /> PROPERTY OWNER'S NAME/COMPANY NAME in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> Norton Roses <br /> ,Property owner's mailing address if different than well location address indicated above in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> 45th in.from to ft. El Yes ❑No ❑Yes ❑No ❑Unknown <br /> r Plymouth, MN 55446 <br /> SCREEN/OPEN HOLE <br /> WELL OWNER'S NAME/COMPANY NAME Screen from to ft. Open Hole from to ft. <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 IENo Obstruction <br /> Type of Obstructions(Describe) <br /> Obstructions removed? ❑Yes ❑No Describe <br /> y:: PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION Not Present ❑Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type <br /> 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? ❑Ye XI No TN# <br /> GROUTING MATERIAL(S) <br /> Neat Cement <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 /> Bad Role NO CASINGGrouted Role Don Stodola Well Drillin 8 Co Inc 1691 <br /> Licensee Business Name License or Registration No. <br /> 55 7/20/22 <br /> Certified Representative Signureat Certified Rep.No. Date <br /> �a, Jerry Barr <br /> LOCAL COPY H ,: Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />