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MINNESOTA DEPARTMENT OF HEALTH Minnesota Well and Boring H 3 8 8 4 9 4 <br /> WELL County OR BORING LOCATION Sealng No. <br /> WELL AND BORING SEALING RECORD Name Minnlesota Unique Well No. <br /> Minnesota Statutes,chapter 1031 or W-series No. <br /> Henne p S (Leave blank if not known) <br /> Township Name+i[ Township No. Range No. Section No. Fraction(sm.--0 lg.) Date Sealed Date Well or Boring Constructed <br /> Orono 118 23 27 S ; SW Sty 8/31/21 <br /> GPS LOCATION—decimal degrees(to four decimal places) <br /> Depth at Time of Sealing 200 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 it Single Aquifer ❑Multiaquifer WELL/BORING k Measured Date Measured 8/31 lj <br /> 21 ❑Estimated <br /> 736 Dickey Lake Dr, Orono 5 3 6 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 51 ft. r below ❑above land surface <br /> lines,roads,and buildings.N CASING TYPE(S) <br /> ]Steel ❑Plastic ❑Tile ❑Other <br /> y--- 4 f WELLHEAD COMPLETION <br /> W E ', <br /> ' / Outside:J]Pitless Adapter/Unit ❑At Grade Inside: ❑Basement Offset <br /> 'f t ` r` , ❑Well Pit ❑Buried ❑Well House <br /> 1 <br /> ---,--- ---� *--- ❑Well Pit <br /> ./ 7_� ❑Other <br /> s " . ❑Buried <br /> 1 Mile---� , <br /> ❑Other <br /> For temporary borings,provide additional location CASING(S) <br /> information,a site sketch,and geology on a separate page. ts Diameter Depth Set in oversize hole? Annular space initially grouted? <br /> PROPERTY OWNER'S NAME/COMPANY NAME in.from I to 96 ft. ❑Yes ❑No ❑Yes ❑No X Unknown ' <br /> Jim 'Jose h . <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 u� • <br /> WELL OWNER'S NAME/COMPANY NAME Screen from 196 to 200 ft. Open Hole from to ft. <br /> 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? X Yes ❑No Describe <br /> 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 /> drift U OOIETHOD USED TO SEAL ANNULAR SPACE BETWEEN 2 CASINGS,OR CASING AND BORE HOLE <br /> r 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 [Nt No TN# <br /> GROUTING MATERIAL(S) <br /> Grouting Material Neat Cementfrom 1 to 200 ft. yards 15 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 X]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 /> 'ion Stodola Well Drillng Co INc 1691 <br /> Licensee Busines N e License or Registration No. <br /> `" 558 8/31#J <br /> 21 <br /> rfif d <br /> LOCAL COPY -f4epresentative Sign "re Certified Rep.No. Date <br /> El383494 Jerry Barr <br /> Name of Person Sealing Well or Boring <br /> HE-01434-17 ID#53159 11/19R <br />