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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 9 9 9 <br /> No. <br /> County Name WELL AND BORING SEALING RECORD MinnSealiesota Unique Well No. <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> IILNNEP/N (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.—+Ig.) Date Sealed Date Well or Boring Constructed <br /> O t ,3 117 2 1u s' 4 W'Ni ,4 10/ 6/L2 <br /> GPS LOCATION—decimal degrees(to four decimal places) <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 r Single Aquifer ❑Multiaquifer qf� <br /> WELLB 1ORING [2 Measured Date Measured U/ C)/2 2 ❑Estimated <br /> �-h4 iiENCtit LAAL RD., OROAO„ N <br /> il Water Supply Well ❑Env.Well <br /> Show exact location of well or boring 35 391 Sketch map of well or boring f, <br /> in section grid with"X." location,showing property ❑Temp.Boring ❑Others, 4-1 ft. [j below ❑above land surface <br /> lines,roads,and buildings. CASING TYPE(S) <br /> N I I L <br /> Steel ❑Plastic Tile ❑ ther <br /> -1 ,-J__ __I I__ — ri <br /> WELLHEAD COMPLETION <br /> w E T L 0Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: 4Basement Offset <br /> 'h Mile ❑Well Pit ❑Buried ❑Well House <br /> f <br /> _, ,_ _ i ❑Other III Well Pit <br /> s ❑Buried <br /> 1 Mile <br /> _..__.- <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 OWNERS NAME/COMPANY NAME 4 in.from I to 2 56 ft. ❑Yes ❑No ❑Yes ❑No 1 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 /> NAME <br /> Screen from 258 to 268 ft. Open Hole from to ft. i <br /> WELL OWNER'S NAME/COMPANY <br /> A LL A J OAiN.S 1.W OBSTRUCTIONS <br /> Well owner'st's mailing address if different than property owner's address indicated above ®Rods/Drop Pipe ❑Check Valve(s) ❑Debris El Fill ❑No Obstruction <br /> f T.u. I . b 4 142 Type of Obstructions(Describe) DROP PIPE <br /> ST. PAUL, AN. 5 /04 <br /> Obstructions removed? 1.Yes ❑No Describe <br /> PUMP ' <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION ❑Not Present 4 Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type S Uf 1.:e B R a S LE <br /> DRIFT IF •�I ,,�;,> d METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> M No Annular Space Exists LI 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 /> NEAT CE LNT I 2c6 24 <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 STO1OLA WELL CO 1691 <br /> Licensee Business Name License or Registration No. <br /> ,,,,,,,,;>/:„.„ex:47,- .„. <br /> Certified Representative Signature Certified Rep.No. Date <br /> LOCAL COPY H 9 J'R R Y A R R <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />