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MINNESOTA DEPARTMENT OF HEALT N n 6 /Minnesota Well and Boring 39�J Q <br /> WELL OR BORING LOCATION Sealing No. J. <br /> 1 4 2 <br /> County Name WELL AND BORING SEALING RE ORDA H Minnesota Unique Well No. <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> Hennepin (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 /> Orono 117 23 05 SWA SW SW 10/27/22 <br /> GPS LOCATION—decimal degrees(to four decimal places) 1 T 05 <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 A Single Aquifer ❑Multiaquifer 10/27/22 <br /> y90 To� $wa �d � WELL/BORING [ Measured Date Measured El Estimated <br /> 7 4 Water-Supply Well ❑Env.Well <br /> Show exact location of well or boring Sketch map of well or boring 68 <br /> in section grid with"X." location,showing property ❑Temp.Boring ❑Other ft. ®below ❑above land surface <br /> N lines,roads,and buildings. CASING TYPE(S) <br /> * °Steel ❑Plastic ❑Tile ❑Other <br /> * LLHEAD COMPLETION <br /> W e, f <br /> T Outside: ❑Pitless Adapter/Unit ❑At Grade Inside: Basement Offset <br /> f �- <br /> 1'k miiel, • ❑Well Pit ❑Buried ❑Well House <br /> - 1 I .- ❑Well Pit <br /> s ❑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. Diameter Dept t� Set in oversize hole? Annular space initially grouted? <br /> P RTY O WNS NA OMPANY NAME 3 in.from to V 1 ft. ❑Yes ❑No ❑Yes ❑No A 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 /> 101 105 <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 ❑No Obstruction <br /> DRO PIPE <br /> Type of Obstructions(Describe) <br /> Obstructions removed? �► Yes ❑No Describe <br /> PUMP <br /> GEOLOGICAL MATERIAL COLOR HARDNESS OR FROM TO <br /> FORMATION a� <br /> ❑Not Present Present,Removed Prior to Sealing ❑Other <br /> If not known,indicate estimated formation log from nearby well or boring. Type S la.iL E . ItLE <br /> DRIFT 1 105 METHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE i <br /> 2.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 No TN# <br /> GROUTING MATERIAL(S) <br /> Grouting Material NEAT CEMENT from 1 to 105 ft. yards 5 bags <br /> 9 <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 [I 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 Dri 11 ing Co 11191 <br /> Licensee Business Name License or Registration No. <br /> (,/-" <br /> � .. 558 10/27/22 <br /> certified Re resentative Signature Certified Rep.No. Date <br /> JERKY ARLi <br /> LOCAL COPY H 3 9 81. 4 2 Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />