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WELL OR BORING LOCATION MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H399130 <br /> SCounty Name - WELL AND BORING SEALING RECORD Min nle otaoUnique Well No. <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> ALANE?iN (Leave blank if not known) <br /> Township Name Township No. Range No. Section No. Fraction(sm.-,lg.) Date Sealed Date Well or Boring Constructed <br /> O O O 116 23 35 3E5oE ' ,A 12/2 /Z2 <br /> GPS LOCATION-decimal degrees(to four decimal places) 83 <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 X.Single Aquifer ❑Multiaquifer 12129/22 <br /> 1225 RO UA S tl . , OR t „ ,ji WELL/BORING X Measured Date Measured �r +Gr ❑Estimated <br /> V �l 6+ &J rWater-Supply Well ❑Env.Well <br /> Show exact location of well or boringSketch mapof well or boring <br /> in section grid with"X." location,showing property ❑Temp.Boring ID +Other 1 ft. X below ❑above land surface <br /> N a..,), liries,rgads,and,,buildings. <br /> CASING TYPE(S) <br /> __ <br /> ❑X Steel ❑Plastic ❑Tile ❑Other <br /> WELLHEAD COMPLETION <br /> W • E <br /> T Outside:X Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'k Mile ❑Well Pit ❑Buried ❑Well House <br /> s 1Well Pit <br /> ❑ i <br /> ❑Other <br /> ❑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. . Diame,)er Depth ft. Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME 4 in.from to 7 <br /> C R I S di EP A N I E I SSON <br /> ❑Yes [I 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 /> 1225 ORONO OAKS D <br /> in.from to ft. ❑Yes ❑No ❑Yes ❑No ❑Unknown <br /> cORONO, MN. 55356SCREEWOPEN HOLE <br /> WELL OWNER'S NAME/COMPANY NAME Screen from 79 to 83 ft. Open Hole from to ft. <br /> CL IS 4 STEPHANIE £RIKSr ON OBSTRUCTIONS <br /> Well owner's mailing address if different than property owner's address indicated above X Rods/Drop Pipe ❑Check Valve(s) ❑Debris ❑Fill ❑No Obstruction <br /> Type of Obstructions(Describe) drop pipe <br /> Obstructions removed? XYes ❑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 submersible <br /> drift 0 83 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 It No TN# <br /> GROUTING MATERIAL(S) Cement <br /> Grouting Material Neat from 1 to 1.1 3 ft. yards 9 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 pperty? ❑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 /> DUB 3TOD Ak W LL DRILLING CO. ,I L. 1691 <br /> Licensee Business Name ,,, License or Registration No. <br /> '-:3-ei"," - / 12/29/22 <br /> Certified Represen alive Signature Certified Rep.No. Date <br /> Jerry Barr <br /> LOCAL COPY H 399130 Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />